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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE R('E�QUESST# <br /> OWNER/OPERArR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME �— <br /> SITE ADDRESS <br /> HOME or MAILING 5� ADDRESS (If Different from Site Address <br /> ) Street ame Ci Zi Code <br /> CITY Street Number Street Name <br /> STATE Zip <br /> PHONE#1 E%r. APN# <br /> ( 1v LAND USE APPLICATION#(� <br /> 00 <br /> PHONE#Z ��7 <br /> Exr, O <br /> ( l BOS DISTRICTLOCAT717r; <br /> CONTRACTOR/SERVICE REQUESTOR 7 <br /> REQU STO�e ryr ^ <br /> r K/1�'- CHECK If BILLIN� G ADDRESS <br /> PHONE# Exr. <br /> BuSi+�PaMse <br /> HOME o r MAILING ADDIR PS <br /> FAX# <br /> CITY <br /> � STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operatoror 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,Slandards, STATE and FERE L laws. <br /> APPLICANT'S SIGNATURE: //UJ <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAG ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHOWZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: SIO Lt: [@ C f C <br /> COMMENTS: � z� <br /> RECEIVED <br /> JUN 2 2 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: <br /> HEALTI-1 DEPARTMENT' <br /> (� /J <br /> 7" LP�' EMPLOYEE#: / ,. DATE: <br /> ASSIGNED TO: <br /> C� 421 EMPLOYEE#: O DATE: <br /> Date Service Completed (it already completed): <br /> SERVICE CODE: P r EL: a 2_ <br /> Fee Amount: Amount Paid <br /> •�• � �a-S �(� Payment Cate <br /> Payment Type Invoice# Check# r <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/37/2003 SR FORM(Golden Rod) <br /> - - f <br />