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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of BusinessorProperty FACILITY ID# SERVICE REQUEST# <br /> � Y U� <br /> NEI/OP�RA R 7 <br /> L� CHECK If BILLING ADDRESS <br /> FAC-16NAMEI . <br /> SITE A DRESSr� <br /> Street Number Direction v )/ �,nnme ✓1 ZiJCodev <br /> H NE Or M ING ADDRESS (If Different from Site Address) ( �y /,//�// <br /> Street Number rTeet Name <br /> STAT ZIP/ � lC- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Vo <br /> REOlUESTl <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ?01PHQNE# EXT, <br /> H E or-MAILING DDR(ESSI FAAXX#v <br /> ��ip(A'7� ��� ( ) z <br /> CITY STATEI(d 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 FE RAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: �h --� <br /> PROPERTY/BUSINESS OWNER OP BATOR/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 asse t information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it� me or <br /> my representative. �+ <br /> TYPE OF SERVICE REQUESTED: M A <br /> COMMENTS: $ <br /> ?418 <br /> y�C ti OF qRT�4��Y <br /> MEHT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 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 />