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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typeof Business or Property w FACILITY IDSERVICE REQ <br /> � � ` �� �V ��� <br /> OWNER/OPERATOR <br /> V(� CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME <br /> SITE ADDRESS ^20 <br /> (.lreet Number I Direction I a Sfeet Name Cit Zi Code <br /> OME Or AILING ADDRESS (If Different from Site Address) <br /> 1 bN 1,4 Street Number Street Name <br /> CITY STATE ZIP <br /> 4 <br /> PHONE#1 _ ExT• APN# LAND USE APPLICATION# <br /> ( � �0 q( q9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITYCA STATE /'��,/� ZIP 41, S 2-02, <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: ��j�?�.� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ /V <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tisle <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 IAA�ed_to me or <br /> my representative. ��� M� <br /> TYPE OF SERVICE REQUESTED: Aliv OVE <br /> COMMENTS: n <br /> SAN JOgQU� <br /> H�CTy pA "46A/AI <br /> TAt IY <br /> T <br /> ACCEPTED BY: ✓ <br /> , EMPLOYEE#: DATE: <br /> ASSIGNED TO: l 1 A EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P E: <br /> Fee Amount: ( 60 Amount Paid - Payment Date <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />