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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0G7qk3q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY AME 14 ne S Ju u r �/-) .7,. <br /> SITE ADDRESS ( KZD( <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumber Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUS ESS NAM / 1 PHONE# EXT. <br /> C z. Q 7�CC(6ZJr7� n -277- <br /> HOME Or MAILING ADDRESS ^_ 1 / /��/ FAX# ) ^- <br /> CITY /1tE r�rFJT� U ( STATE ZIP �/! <br /> BILLING ACKNOWLEDGEMENT: 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 billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU � _ DATE: I 1 g <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT IS Ot the BILLING 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 pAided to me or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: •V <br /> COMMENTS: , / 4fO /3 <br /> qF NAY <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � Ci EMPLOYEE#: �.� (/�1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: l�j 6-2- <br /> Fee <br /> Fee Amount: Amount Paid .,/ SZ Payment Date 5 � <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />