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SAN JOAQL,ttq COUNTY ENVIRONMENTAL HEALTH _PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ` 5 ! C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS lk O o „t V 5 �f✓R ity I 'Code <br /> Street Number Direction Street Nam Ci Zi Co <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> C A c T9TE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> A109 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> f <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, S and FEDERAL laws. p <br /> APPLICANT'S SIGNATURE DATE <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tilie <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: w . �f'' Vu5 u <br /> COMMENTS: <br /> ACCEPTED BY: C-U EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: u� r P/E: <br /> Fee Amount: (5 Amount Pale16 Payment Date j <br /> Payment Type Invoice# Check#"u7 75/D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />