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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Biness or Property FACILITY ID# SERVICE REQUEST# <br /> OWN E /OPI]�aATOR <br /> 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME I iJ 6C K <br /> SITE ADDRESSA�^ <br /> bQN Street Number Direction Street Name -f\I�'jHOME or Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> P #1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, t e un ersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project s ciflc ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business id tified on this form. <br /> I also certify that I have prepared this ap li ti n and that the work to be performed will be done in actor an e with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST T d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> a <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provldPA PAYMENT <br /> my representative, do RECE ii iiiiii ED <br /> TYPE OF SERVICE REQUESTED: r <br /> U 2 2 <br /> COMMENTS: �f.,3�_ l➢iJ <br /> ] V SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: VU i(y EMPLOYEE#: DATE: <br /> ASSIGNED TO: v EMPLOYEE#: DATE: l� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid p Payment Date <br /> Payment Type Invoice# Check# �- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />