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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST SERVICE REQUEST # <br />�. FACILITY ID # <br />Type of Business or Property <br />�y CHECK ifBILLIN�ESS1 <br />OWNER I OPERATOR <br />FACILITY NAME <br />SITE ADDRESS <br />steel <br />HOME Or MAILING ADDIRAJ <br />I <br />I <br />Ext. <br />EXT. <br />CITY <br />PHONE #1 <br />tzFf) L <br />PHONE #2 <br />REQUESTOR <br />C jA- <br />:r Direction <br />-J--- <br />Different from Site Address) <br />APN # <br />cLJ T <br />CI zI Code <br />S• <br />Street Name <br />STATE ZIP /l <br />L4-1�.'. lJ <br />LAND USE APPLICATION # <br />-- &0 <br />;OS DISTRICT II LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />D Tp V:>O 0 " <br />PHONE # <br />CHECK if BILLING ADDRESS <br />EXT. <br />j BUSINESS NAME <br />FAx # <br />EHOMEMAILING ADDRESS ,,` USTATE ZIP/ f�( , C � `'1 S <br />BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. <br />.k,APPLICANT'S SIGNATURE:( �7 1 ����1� DATE: 2 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR I 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, 1, the owner or operator :-e property lOcaed at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or er, _--..ental/site asses inert information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available anc 2- " Same time It IS t^ to me or <br />my representative. to <br />TYPE OF SERVICE REQUESTED: '� `^ i b �� i�v�'1 �( eel <br />COMMENTS: l <br />M�Y21 <br />8aANJOAQUN EWORO rN QUI <br />EALTH -j�yT� <br />ACCEPTED BY: LS LO EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:w<l1� <br />EMPLOYEE #: DATE: _ <br />Date Service Completed (if already Completed): SERVICE CODE: Z <br />Z`?) PIE: <br />Fee Amount: r 4 Amount Paid s � � Payment Date 5 <br />Payment Type Invoice #7 <br />Check # 9) Received By:,,//") <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />