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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LJtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> C• r C> S <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Dir'ection <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C (1 `- t; Street Number - l -Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ^ PHONE# EXT. <br /> t• ,. ` .� CYC <br /> HOME or MAILING ADDRESS FAX# <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 /> 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: (;� �1�c q DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is me or <br /> my representative. 1' <br /> TYPE OF SERVICE REQUESTED: v/f G (j I►/ <br /> COMMENTS: <br /> 201? <br /> SAN JOAQUIM C <br /> NgfrN p �L <br /> ,t NT <br /> ACCEPTED BY: 1 Q//al(// l 6'07 <br /> 7 EMPLOYEE#: DATE: <br /> ASSIGNED TO: f t C t 1 t/h `II 1 , r EMPLOYEE M DATE: <br /> ja <br /> Date Service Completed (if already completed): SERVICE CODE: I;iJ/ PIE: <br /> Fee Amount: I C� Amount P i I� �i Payment Date <br /> Payment Type Invoice# Check# Received By:Jr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />