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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ro <br /> Ovv R/OPERATOR , CHECK If BILLING ADDRESS■"' <br /> CIL]q7Y NAME <br /> S TE ADDRESS <br /> 5J Street Number Dlrection S`t'reet Name Zip Codb— <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> � <br /> o��1 4�� _��5 3 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE FEDERAL laws. <br /> APPLICANT'S SIGNATURE:. . } DATE:</© , <br /> PROPERTY I BUSINESS OWNER eERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT [3 <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 assess t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It ISIOr <br /> my representative. ��i r <br /> IVPA <br /> TYPE OF SERVICE REQUESTED: )C C CU 16,0 <br /> COMMENTS: 441 19207 <br /> SAN 0' QU/N CO <br /> H�CTH 0 N7A� 1' <br /> ACCEPTED BY: V ir1 1 V qCi-17 EMPLOYEE#: DATE: cj <br /> ASSIGNED TO: IV l S EMPLOYEE#: DATE:d01 / <br /> fil I <br /> Date Service Completed (if already completed): SERVICE CODE: �) ( ✓PIE: <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 />