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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS A. / L <br /> L Street Number Dir tion Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /+q <br /> Street Number J '/�}I 11 -t /M 'Street Namec' <br /> CITY STATEC-14 <br /> Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 'C. STATE CC- ZIP 9�� 1 <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: /� i DATE: <br /> PROPERTY/BUSINESS OWNER OPE TOR 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 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 pr��i�d to me or <br /> my representative. <br /> rlrt�c <br /> TYPE OF SERVICE REQUESTED: I L �I <br /> COMMENTS: utc 012016 12016 <br /> l �1 C�/�C,� H EN q <br /> /�1 w COUN <br /> EACrjf')FPAQAfNr <br /> ACCEPTED BY: 7 /I QA I/Ar EMPLOYEE M DATE: <br /> ASSIGNED TO: I ' 'I ha <br /> Wvt'�l EMPLOYEE DATE: <br /> LLY1 I <br /> Date Service Completted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: = Amount Paid Payment Date F <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />