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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � <br /> SR. 00? 1aa3 <br /> OWNER <br /> If <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME ry � �� � I LLl <br /> SITE ADDRESS <br /> u` Pro <br /> [reef umber I Direction Street Name Ci Ziu Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> c, _- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( v 9) <br /> P�c(p. l9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L� !^ CHECK if BILLING ADDRESS <br /> 11 <br /> BUSINESS NAME T •l �. P t # 8q - Gn EXT. <br /> ZF <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 I BUSINESS OWNER 0144ATOR/MANAGER ❑ 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 provided to me Or <br /> my representative. <br /> AbA <br /> TYPE OF SERVICE REQUESTED: I V ZL COMMENTS: <br /> S,gA,19Cj <br /> F R Q(N 9 <br /> qFN qUN <br /> R t <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: l ? G' 0 EMPLOYEE#: DATE: l ` <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 n PIE: <br /> Fee Amount: 1�2 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 />