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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nRVICE REQUESTT-# <br /> FOL"Cl --"- I f< 0 <br /> OWNER f OPERATO <br /> Se--- <br /> (����Z� �I✓1G '> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> v <br /> V ct C3- SITE ADDRESS��T O s ✓ Q rt <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different fro Site Address) 5 f � <br /> 91 <br /> Street Number Street Name <br /> CITY STATE G14- ZIP 9 h 3 0 <br /> G( rUY <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> F OME or MAILING ADDRESS FAX# <br /> t ( ) <br /> CITY STATE ZIP <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C DATE: <br /> PROPERTY/BUSINESS OVVNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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. T <br /> TYPE OF SERVICE REQUESTED: bI) [ L U{ ✓�I L U D <br /> COMMENTS: <br /> 0 7 2 18 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENlAL <br /> HEALTH DEPART ENT <br /> ACCEPTED BY: f EMPLOYEE#: 0o G' DATE: 1�— o I <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: Z I <br /> Date Service Complete'd (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: I 2 (J Amount Paid j '1, Payment Date ? 1 <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />