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SAN JOAQu„a COUNTY ENVIRONMENTAL HEALTH i6.-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U;3` G <br /> OWNER/OPERATOR <br /> \�\ CHECK if BILLING ADDRESS <br /> IFACILITY NAME <br /> � <br /> SITEADDRESS <br /> t Street Number Direction M� Street Name City Zi Code <br /> HOME OIMAILING�ADDRESS (If Different from Site Address) ( Iw C <br /> Street Number Street Name <br /> CITY ^ STATE ZIP <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERV, ICE REQUESTOR <br /> REQUESTOR �2) <br /> l CHECK If BILLING ADDRESS L� <br /> BUSINESS NAMEXT <br /> t �(O P E# 1�Sa E <br /> V � <br /> HOME or MAILING ADDRESS <br /> 0 <br /> CITY 'n STATE C' ZIP <br /> BILLING ACKNOWLEDGEME'N`T: 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 /> 1 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 TE l�dEDER L laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not 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 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. �r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: IZJgY <br /> �0 �8 �,pl <br /> NF L11,90 M��,o�N <br /> _ �pARTMF <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I h c 1 Z EMPLOYEE#: DATE: �- `S-- /4 <br /> Date Service Completed (if already completed): SERVICE CODE: C P 1 E: <br /> Fee Amount: I�Yr� 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 />