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SAN JOAQU..4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Roo <br /> OWNER/OPERATOR nn <br /> 1 I CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS , ! C �J r <br /> Q r\ f <br /> t (r Street Number Direction +'h Street Name cityi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> N�� Street Number Street Name <br /> CITY STATE Z I P <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> yE � <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ('L ) !5 � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR`�J <br /> b CHECK If BILLING ADDRESS <br /> + <br /> BUSINESS NAME PHONE# EXT.�` { bV1Y�i � 1I Cj O� <br /> HOME or MAILIN,GG IJDDRESS FAX# <br /> I C�`11 1 J 1 Iti ( ) <br /> CITY ' rl° � �j 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 /> 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: � y 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 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. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A <br /> N 052017 <br /> y� V H4OF N EENT <br /> ACCEPTED BY: a— /�� OAoA EMPLOYEE#: DATE: C <br /> ASSIGNED TO: I a— t� l T/r EMPLOYEE#: DATE: 7� J <br /> Date Service Completed (if already completed): SERVICE CODE: l�G011) l P E: <br /> Fee Amount: I G� Amount Paid Payment Date 1 S <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />