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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ^ SERVICE REQUEST# <br /> OUCH'(/ <br /> OWNER/OPERATOR I CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESSS ` �PZs) <br /> 7 Street Number Direction � v1 � V Street Name CI Code <br /> HOME Or MAILING AQDRESS (if erent from Site Address) <br /> / Street Number C)C ) Street Name <br /> CITY 4c� <br /> C. 4\ U V-) STATE ZIP/y <br /> PHONE#1 4 V EXT. APN# LAND USE APPLICATION# �( <br /> (7i `77 � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P # ExT. <br /> A- <br /> HOME or MAILING ADDRESS FAX# <br /> G`7 -7 v �o �3a k- ( ) <br /> CITY U f V U� STATE �� ZIP C� <br /> V� �C� 6 <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,STAT and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: \ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ 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 pr ov to me or <br /> my representative. r <br /> TYPE OF SERVICE REQUESTED: �ll i In )24 Lh //1 <br /> COMMENTS: PtR <br /> NiR pN IN COU <br /> HUFpq� <br /> ACCEPTED BY: EMPLOYEE#: & DATE: <br /> ASSIGNED TO: D EMPLOYEE#: vv DATE: 1 1 I <br /> Date Service Completed (if already completed): SERVICE CODE: (" , PIE: <br /> I Lf U <br /> Fee Amount. '(f(J Amount Pai ��� d� Payment Date /l <br /> Payment Type 5� Invoice# Ch k# 74 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />