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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _SERVICE REQUEST i <br /> / OWNER/OPERATOR <br /> (� \ b-(2 �O _i7 J& CHECK if BILLING ADDRESS <br /> ' \ Ll I'1 C �GC C{. <br /> FACILITY NAME W J C � � 1 G C T <br /> �/�j ;� f <br /> SITE ADDRESS %� Y Q M If V( eu, <br /> J' ` U� <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> / <br /> + Street Numb^r Street Name <br /> CITY _ r <br /> STATE /' ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) e�C 1 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> cC w c-:- eS <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 /> 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: 140 DATE: — <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT I%t 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 locate t the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess <br /> m on <br /> p <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It is T <br /> my representative. PftI <br /> TYPE OF SERVICE REQUESTED: Q l Q �'2 Z <br /> COMMENTS: JOA <br /> MFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ry I EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): $ERVICE CODE: PIE: O✓ <br /> Fee Amount: Q, 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 />