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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UST# <br /> TS <br /> OWNER/OPERATOR <br /> Q CHECK if BILLING ADDRES <br /> FCILITY NAME <br /> Sil E ADDRESS <br /> C <br /> \� eet um Direct n Street Name Ci " Zi Code <br /> HOME Or MAILING ADDRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZI <br /> �V <br /> PHONE#1 EXT APN APPLICATION�5 <br /> LAND USE A # <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR PA VA <br /> REQUESTOR ��` <br /> CHECK If BILLING AD <br /> B SINESS NAMEPHONE# Jur. y <br /> HOME or MAILING ADDRESS FAX# eA J01-100/Al X019 <br /> 'P O ( ) M /ROUN7Y <br /> CITY G I tJSTATE ZI PqR T"C <br /> 1°' NT <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 preOIN ,ORMATION: <br /> atio a at the work to be performed will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes,S ED I S. <br /> APPLICANT'S SIGNATU DATE: l/ �,� �9 <br /> PROPERTY/BUSINESS OWNERATOR/M NAGE ❑ OTHER AUTHORIZED AGENT ���� <br /> If APPLICANT G PARTY, roo f authorization to sign is required Tine <br /> AUTHORIZATION TO RELWhen applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the re ease of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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: [1� <br /> COMMENTS: �I ,P--d Jtr,v //_ ' LJ� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: U { DATE.' <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE• O Z <br /> Fee Amount: Amount Pai �d D Payment Date <br /> O <br /> Payment Type Invoice# Check# 33 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />