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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# pSERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �� 7 <br /> Street Number Direction Street Name <br /> cityZi Code <br /> HOME Or MAILING AnnDFCC of Different from Site Address) /A�, v7 <br /> r �� '4 )Steet N/��[' <br /> {, Street Number <br /> CITY C k� Slr! ZIP <br /> UC <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ! PHONE# EXT. <br /> Y Y I G V,e - O <br /> HOME or MAILING ADDRES FAX# <br /> V\^,-V i CC4 to ( ) <br /> CITY (n T 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 /> 1 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: A ll� U �u U ICA kov 03 DATE: - - <br /> PROPERTY/BUSINESS OWNER OPERATOR 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, 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 asses 1p,mation <br /> t0 the SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS SOOn aS It IS aVallable and at the Same time It IS . <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Mq <br /> COMMENTS: <br /> II � CJOA <br /> 1? <br /> FN VQIJ�N <br /> � H�CTjSEP EOUNTy <br /> lel C-' AR <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �' EMPLOYEE#: DATE: Gam_ f`� <br /> Date Service Completed (if already completed): SERVICE CODE: ✓P IE: <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 />