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vv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />c CHECK if BILLING ADDRESS <br />FACILITY ID # <br />} <br />SERV CE REQUEST # <br />OWNER / OPERATOR <br />+, I <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />STATE < '/A ZIP )!57L7() O <br />SITE ADDRESS—;L) <br />/ /Street Number Direction <br />y/���r I <br />V Street Name <br />T" O,` <br />Ci <br />" <br />ZiJCode� <br />HOME Or MAILING ADDRESS (If Different from Site Address) /�j JO 76 <br />lStreet Number <br />r �— <br />Street NaMe� <br />CITY r� n ^ j <br />MFH <br />pF <br />STATE ZIP <br />`` o <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />C�,-� -11 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />c CHECK if BILLING ADDRESS <br />BUSINESS NAME/� <br />} <br />PHONE# EXT. <br />H - a� t <br />HOME or MAILING ADDRESS <br />+, I <br />FAX# <br />CITY C oC <br />STATE < '/A ZIP )!57L7() O <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. RAL laws. <br />APPLICANT'S SIGNATURE: DATE: 111 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT [3If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />V� <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It Is providP�me or <br />my representative. � <br />,/ r /� <br />TYPE OF SERVICE REQUESTED: V I C • � <br />COMMENTS: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />a <br />hI F QUA <br />MFH <br />pF <br />q N <br />�TMFN <br />ACCEPTED BY: �. `� <br />EMPLOYEE #: <br />DATE: 2D / <br />l <br />ASSIGNED TO: ��— <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: �'— <br />P / E' V <br />Fee Amount: 0 <br />Amount P <br />(O � U D <br />Payment Date(1-/X// <br />` ` 67 <br />Payment Type C J� <br />Invoice # <br />Check # 41 <br />L� <br />Recei d By: <br />COMMENTS: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />a <br />