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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 n <br /> A���l �,--�11 aat Z— _ CHECK if BILLING ADDRESS <br /> FACILITY NAME ll��� <br /> $-7 L- <br /> SITEADDRESS <br /> m b AV e- 6 <br /> Street Number Direction I Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number J Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR G ^v�V(� _/� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Qrza&Q 7M)S-7/-j (2(q <br /> HOME Or MAILING ADDRESS A }— FAX# <br /> CITY STATE CC., ZIP � S <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 DATE: <br /> PROPERTY/BUSINESS OWNEf 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 provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: l ! <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �. I > EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: l /y, <br /> Fee Amount: 1---4-)011 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />