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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LGPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name Cit Zip Code <br /> HOOr MAILING ADDRESS (If Different from Site Address) t t <br /> Street Number Street Na e <br /> M <br /> CI STATE ZIP 9 <br /> CA <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 6/0 <br /> PHONE# EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FA <br /> "t ) <br /> CITY /1 STATE ZIP <br /> / ' I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized age t 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, STTE and FEgERAL IaWS. <br /> APPLICANT'S SIGNATURE: % ! DATE: <br /> PROPERTY/BUSINESS OWNER❑ IWERATOR/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 ass ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time; �to me Or <br /> my representative. I� <br /> TYPE OF SERVICE REQUESTED: Q <br /> COMMENTS: <br /> h, EiyI,"Yov, CO <br /> ACCEPTED BY: J C , EMPLOYEE#: I?�?3 DATE: <br /> ASSIGNED TO: LLAi/1 IEMPLOYEE#: 3 -16( DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: \�C S`3 Ip"': <br /> E: ' <br /> Fee Amount: qr . Amount Pait ! /� b� Payment Date <br /> Payment Type I /� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />