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SAN JOAQUSt.. COUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR L\ wv/� Aj4 CHECK If BILLING ADDRES <br /> FACILITY NAME / <br /> SITE ADDRESS <br /> 2 <br /> f� 1v <br /> Street Number Direction r"1 -eet Name i Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> EX7. BOS DISTRICT LOCATION CODE <br /> C 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �— <br /> y1►�ZU CHECK if BILLING ADDRESS <br /> BUSINESS NAME 111\ PHONE#' EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY $TATE ZIP I <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, STATE and)FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: 2- I <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 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 /> 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: Ex- I n 1�" / ` -� inn k :< <br /> COMMENTS: n`4nAq, <br /> SAIJO <br /> EfVVAOUIfV COU <br /> i;EALTy DOAI'V`I TA I7Y <br /> 1 a <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I 1 V' ., !l EMPLOYEE#: DATE: <br /> Date Service Completbd (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 152 to-�' Amount Paid 4, ts2_ bo Payment Date 2v �— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />