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SAN ,IOAQWI , .;OUNTY ENVIRONMENTAL HEALTH DL,ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C(to'a- <br /> OWNER/OPERATOR //�), <br /> \ ` P •/� r• Ch'ECK if BILLING ADDRESS <br /> FACILITY NAME Y n n <br /> Pf <br /> SITE ADDRESS 1L <br /> J� r Direction et Na Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ,v Stre Number Street Name <br /> i <br /> CITY STATE zip / <br /> PHQNE#1 EXT• # LAND USE APPLICATION# <br /> c NE#1—a�3y—t �v3 <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 /> I also certify that I have prepared this application and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TATE an 1W S. <br /> APPLICANTS SIGNATUR <br /> TE: <br /> PROPERTY/BUSINESSOWNER OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT lS n the BILL G PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS INFO MATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize ter ase of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It Is available and at the Same time It Is provided to me Or <br /> my representative. <br /> TYPE O" �D: <br /> COMMEtl� <br /> N?R 15 <br /> SOAOUI m <br /> AN JHpPENTAL <br /> TMEN <br /> EA1 AR <br /> ACCEPTED BY: lV—�+� \ ` _ EMPLOYEE#: 3�// DATE: / <br /> ASSIGNED TO: Li lM t t <br /> EMPLOYEE#: j v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 06/ PIE:�✓/O <br /> Fee Amount: Amount) Paid - Payment Date <br /> O <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />