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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �� �FA j�TY IDI (J,r � ,SERVICE T# <br /> l7 <br /> OWNER/OPERATOR _ ll/% <br /> C / 7A 146 CHECK If BILLING ADDRESS <br /> FACILITY NAME - <br /> SITE ADDRESS r C <br /> o sf �iZ- <br /> tree 'Ler Direction Street}Jame ei \ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS�. <br /> BUSINESS NAME PHONE# EXT: <br /> �-S/ <br /> HOME Or MAILING ADDRESS / FAX# <br /> CITY ( STATE ZIP GIf <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 tha,Lpe rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED Z4L <br /> APPLICANT'S SIGNATURE: DATE:�' 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tfr(e <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. A <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: pJO <br /> ti R N/NC 419 <br /> y�Fpq�NTq���Y <br /> ACCEPTED BY: EMPLOYEE#: '7 -) J DATE: <br /> ASSIGNED TO: U' * / EMPLOYEE#: DATE: /—z— <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: (5 Amount Paid Payment Date <br /> Payment Type _ /a Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />