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SAN JOAQUIN QNTY 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 /> i <br /> FACILITY NAME Mon <br /> SITF <br /> Street Number Directs n / treetQme H- 5N�Ibm- �- <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STAT <br /> Ce - (il�' C c\�ZIP �7s cp66 <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t r CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILIG ADDRESS FAX# <br /> �1 r c ( ) <br /> CITY 5 A-GCIC-\ y � 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: ^L,����ZCC DATE: 7" I LI <br /> PROPERTY/BUSINESS OWNERt" 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 assessor RA formation <br /> tO the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It ispARNG r <br /> -'� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: c� 1 Aly,/ <br /> LA hr4r 1[404? COIJIV. <br /> pARrMFN <br /> ACCEPTED BY: c' EMPLOYEE#: DATE: <br /> ASSIGNED TO: 0C� `C EMPLOYEE#: DATE: -7 <br /> Date Service Completed (if already completed): SERVICE CODE: t' P/E: <br /> Fee Amount: C " Amount Paid Payment Date CEC/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />