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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS\c;\�-\C <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> fII- Street Number Street Name <br /> CITY STATE ZIP <br /> cq <br /> I e— I v I <br /> PHONE#11 EXT. APN# Z LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE / <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> 0-1 \ Yv <br /> BUSINESS NAME PHONE# EXT. <br /> t -- - ., <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ;— STATE ZIPF_ <br /> �`-]. S <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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: s-L>- c!byl--, <br /> PROPERTY I BUSINESS OWNER OPERA19111MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ,�A� 06219 <br /> SAN JOACUIN C A TM <br /> ENVIRONMPE <br /> � PA MENT <br /> HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I E: <br /> Fee Amount: Amount Paid Q �( Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />