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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Aly- civ �K <br /> OWNER/OPERATOR , <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> rrSIITE ADDRF� <br /> v� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILI G ADDRESS (If Different from Site Address) j� <br /> `or �X Street Number Street Name <br /> CITY /}/ W4� e-4- <br /> OMwSTATE n� ZIP <br /> PHONE#1 ` ' ,v EXT. APN# LAND USE APPLICATION# <br /> PHONE 2 EXT. BOS DISTRICT j, LOCATION PDE <br /> N CONTRACTOR/ SERVICE REQUESTOR t <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS E] <br /> BUSINESS NAMEPHONE# Exr. <br /> HOME Or MAILING ADDRESS 'p,P. O vO y FAX# <br /> CITY e-4 <br /> A,Z4 STATE ZIP q�rJ 7 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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, T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ VOPERATOR/MANAGER ❑ OTHERITHORIZED AGENT <br /> If APPLICANT is not the BILL/NG PARTY,proof of authorization to sign is required Tit l <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (7), 40-2 <br /> COMMENTS: /� PAYMENT <br /> RECEIVED <br /> APR 13 2007 <br /> ACCEPTED B EMPLOYEE#: ME BI1TE: O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed: SERVICE CODE: / PIE: <br /> Fee Amount: 00 Amount Paid l Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />