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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# REQUEST# <br /> SrSEFWICE <br /> OWNER/OPERAT <br /> C CK if BILLING ADDRESS <br /> FACILITY NAME <br /> 1 <br /> SITE ADrrDRE�441re<e , <br /> y ��J� <br /> / b Direction Street Name I` C' Zi`C"de <br /> HOME Or MAILING®ADPES�Differ�t fro Site Addr )` /T Street Number Street Name <br /> CITY $TATE ZIP <br /> PHONE 1 _/' EXT. APN# � //ice J� •/ LAND USE APPLICATION# <br /> PHO E;t2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 applic ion and that the work to b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STA nd FE ERAJL/laws. <br /> APPLICANT'S SIGNATURE: G �/[/ G%�',� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT ❑ <br /> If APPLICANT IIs 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?;thnabove <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment ition <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provi <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U V <br /> COMMENTS: Pi <br /> ✓Q <br /> F <br /> FNT <br /> ACCEPTED BY: EMPLOYEE#: IN DATE: Zo . <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 523 J <br /> PI : G <br /> Fee Amount: Amount Pa' �P�O u� 11 <br /> Payment Date �3 <br /> Payment Type Invoice# Check# 2 / Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />