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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR 0A,T i a <�� <br /> (Q4 <br /> I I 0 CHECK if BILLING ADDRESS E] <br /> FACIUTYNAME OE / C/tQ�{��(j/t�(�j,� <br /> SITE ADDRESS 30 5 C I r ( (� $ 5•-h— <br /> Street Number Direction Street Name city Zip Code <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> 2 a J'Ll Street Number Street Name <br /> CITY C STATE <br /> //,� ZIP - <br /> l LC-i <br /> PHONE#1 EXT T PN# LAND USE APPLICATION# <br /> PHONE#2 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 FAX# <br /> CITY 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 /> also certify that I have prepared this applicatio and that the o k to be pert med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE d FEDERAL 1 S,' <br /> APPLICANT'S SIGNATURE;/ DAT <br /> PROPERTY/BUSINESS OWNER❑ �" 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 asses sm jmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It Is pr 70, Ar <br /> my representative. ' 1 A�l'`�f� C <br /> TYPE OF SERVICE REQUESTED: 'UO U C <br /> COMMENTS: L W Z l>� SAN dOAQU+ <br /> C-(6a- ENVIRO N COU <br /> HEA1-TN DEA 041- TY <br /> r <br /> ACCEPTED BY: �� U Y,i�.l EMPLOYEE#: DATE: <br /> ASSIGNED TO: L`t�S EMPLOYEE#: DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: L PIE: t�G <br /> Fee Amount: l 77 p Amount P � ;^ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />