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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> l Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A- <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY DAME <br /> SITEADDRESS <br /> / Street Number Direction Street Nam? nrn, Zic Cede <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (Zov) Of 2 1 0 - <br /> PHONE k2 ^7 EXT, BDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR OR SERVICE+ REQUESTOR <br /> REQUESTOR <br /> 1�JU CHECK if BILLING Ai1DRE5 <br /> BUSINESS NAME r - PHONE# ExT. <br /> l�Ia— <br /> HOME or MAILING ADDRES FAX# <br /> ( } <br /> r <br /> CITYSATE ZIP <br /> BILLING ACKNOWLEDG JIErg I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be bilied to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatA and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE FEDERAL laws. <br /> APPLICANT'S SIGNATURE: yy DATE: <br /> PRCPERTYI BUSINESS OWN OPERATOR I MANAGER Ltr--J OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICAN iS not the B1LLfNG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION. When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. *� <br /> TYPE OF SERVICE REQUESTED: �r✓� E{`!T <br /> COMMENTS: fJFCfJVhU <br /> SAN JN COUNN <br /> E.NVIROMEN7At-ENT <br /> TN pEpARTM <br /> ACCEPTED BY: EMPLOYEE : DATE: G}_ a <br /> ASSIGNED TO: `�,-. 1 reZ_ EMPLOYEE#: DATE: !r <br /> Date Service Completed (if already completed): SERVICE CODE: 010PIE: I O�D- <br /> Fee Amount: J -5U� Amount Paid C� Payment Date <br /> Payment Type C- � Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> h <br /> i <br />