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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERA OR _ <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> n <br /> SITE ADDRES 17/ u n (CJ <br /> Street umber Direction CZ�ilo V GAgal io <br /> HOME Or MAILING ADDRESS (If Diff m 'e ddress) <br /> Street Number <br /> CIN AT ZIP <br /> w <br /> PHONE#1 r ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (✓/ — DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 assessment in rmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provide � <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �O <br /> COMMENTS: SAN�� �1Jr <br /> H '�N%q USN C <br /> FALT �pRT uNn. <br /> �►T <br /> ACCEPTED BY: f,-� . '!Z n Z'-L EMPLOYEE#: DATE: <br /> ASSIGNED TO: Y� .L., EMPLOYEE#: DATE: <br /> o�L� <br /> Date Service Completed (if already completed): SERVICE CODE: / PI/E: l <br /> Fee Amount: .---- Amount Pai /3b L-') D Payment Date <br /> Payment Type Invoice# Check# Received By <br /> OT <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />