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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> lif�Uo �S T�' 0 0T(� o/ <br /> OWNER/OPERATOR /�� � r ///a 5 0 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction / Street Name CI Zl Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY <br /> 4I�S �� /�`G /� STATE IP <br /> PHONE A EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �\� QD Sj f _��'n <br /> �VII d� 'Tj CHECK If BILLING ADDRESS <br /> BUSINESS NAME i PHJJNE# EXT. <br /> HOME or MAILING ADDRESS AX# <br /> CITY -5-1-72Cl/ZZ JI1 STATE �� ZIP Q <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 b. °performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE <br /> X' a:77"JAPPLICANT'S SIGNATURE: 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 Tirie <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 environments ssment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the sad to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: SEP 7 <br /> COMMENTS: SAI y J <br /> HEALTHAQIJON MEyT��7y <br /> gRTiv7FNT <br /> ACCEPTED BY: ut I EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: a I 1-7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ' �)�► <br /> Fee Amount: L.� (_% (j Amount Paid Payment Date <br /> [Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />