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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVI ER UEST# <br /> gq <br /> OWNER/OPERATOR <br /> ' A ^� ( 1 t, CHECK if BILLING ADDRESS <br /> FACILITY NAME�j (�EDI <br /> � /�JJ <br /> CLInSJ fffPk, <br /> ITZ S iStreet Number tion et Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) <br /> ;79 �� J (QStreet Number Street Name <br /> CIT STATE IP <br /> �r/NCAC / <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME (' /> PHONE# EXT. <br /> HOME or MAILING ADDRES6 FAX# <br /> CITY / ' A /� A 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: 477 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG R ❑ 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pA�d to me or <br /> my representative. �I'`1I yM <br /> TYPE OF SERVICE REQUESTED: CvS�t <br /> COMMENTS: AY <br /> 16 2� <br /> S M'JO 19 <br /> NF,g NV o A14f IV 11 ry <br /> R/ A <br /> T,kFNT <br /> At <br /> ACCEPTED BY: f 1 f a EMPLOYEE#: g� DATE: 5 / JG� <br /> ASSIGNED TO: )r EMPLOYEE#: DATE: l `t l t�r <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 />