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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / ? <br /> CHECK If BILLING ADDRESS <br /> i <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �x-' ' W'4 r 1 Direction v v V Stree Name" �C' i v � 'Zi Gode� <br /> HOME Or MAILING ADDRESS If Differ nt from Sit Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESStl <br /> BUSINESS NAME PHONE# �T, <br /> HOME Or MAILIN DDRE y FAX# ) <br /> 6 <br /> 2- <br /> CITY { 4�/ l STATE ._LI 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 applicati d that the work to be perfor d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT n EDERAL IaWS. <br /> APPLICANT'S SIGNATURE: DATE:i� - <br /> PROPERTY/BUSINESS OWNER 110ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tir1e <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ����r•L �F/� G'C' fi� (r'G/I�S�V' �,/������ A/AY V�® <br /> SANDOA Q ,J ?919 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED T0: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P4 E: <br /> Fee Amount: l Amount Paid /sem Payment Date <br /> Payment Type Invoice# Check# 'g G'Gj Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />