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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines or Property FACILITY ID# SERVICE REQU EST# <br /> OWNER/OPERATOR <br /> AAt 17Z— %y� ! � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSSteet <br /> 117 S Street Number Direction c rName city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number /� Street Name <br /> CITY ` ` ¢� ZIP <br /> 9, �z <br /> PHONE#1 EXT-7N# LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> --d7 U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ❑ <br /> CHECK If BILLING ADDRE <br /> BUSINESS NAME PHONE# ft-7; %Vr <br /> HOME Or MAILING ADDRESS FAX# JUN D <br /> ( ) l V <br /> CITY STATE ZIP FNVgQI/lN <br /> 0U <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agen tyC�l. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project ENT <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, S A E and FEDERAL s. <br /> APPLICANT'S SIGNATURE: DATE: bs-- <br /> PROPERTY/ <br /> BUSINESS OWNER OP RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is hot 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 environmenta/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /I � h <br /> COMMENTS: \K <br /> ACCEPTED BY: )T EMPLOYEE#: DATE: <br /> ASSIGNED TO: / �,/O n EMPLOYEE#: DATE: v�� �. <br /> Date Service Completed (if already co pleted): SERVICE CODE: C-)I(o1 PIE: <br /> Fee Amount: hfocD Amount Paid �� n�-� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />