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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICUFST# <br /> �,A-) /- ktr4� <br /> OWNER/OPERATOR <br /> /O jl� ��- �/���FY�s'�D<' CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> SIDE ADDRESS <br /> Street Number Direction Street Name citvZi Co e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> Ex . <br /> HOME or M ING ADDRESS FAX <br /> CITY STATE / /, ZIP Q�J Q/ <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE AI,I <br /> APPLICANT'S SIGNATURE: - --yam DATE: '4 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ ANA R ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PA Ty roof of authorization to sign is required Tire <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 provided to me or <br /> my representative. PAY NT <br /> TYPE OF SERVICE REQUESTED: RECEI ED <br /> COMMENTS: APR 18 019 <br /> SAN JOAQUIN C DUNTY <br /> ENVIRONME ITAL <br /> HEALTH DEPAR MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: _2_ <br /> Fee Amount: Amount Paid4P — Payment Date <br /> Payment Type S Invoice# Che,;k# 610 ?� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />