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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 /> FACILITY NAME <br /> SITE ADDRESS /J /� / ' <br /> 7 Street Number Direction / O"�^ ` Street Name L= !�C''C��' ��' Cit s�1 _ i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 6^ i�%�, �c_ c' Street Number ' Street Name <br /> CITY STATE ZIP <br /> ��c c c 4-, 4 c1s2 <br /> PHONE#1 EXT. qPN# LAND USE APPLICATION# <br /> (toy) �J03 -- 3 69 <br /> PHONE#2 Exr. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY 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 SIGNATURE: ,z,/ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ..- <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 2 b 7�� �i1� S AuG 1 0 2006 <br /> (�� N ORO U/N COV&, <br /> TY <br /> 1lEACTy p '4 MENT <br /> ACCEPTED BY: EMPLOYEE#: �) DATE: <br /> ASSIGNED TO: EMPLOYEE#: 6JQ DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: b <br /> Fee Amount: U` Amount Paid bPayment DateV R2 <br /> Payment Type `� Invoice# Check# \ .Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />