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SAN JOAQUII. OUNTY ENVIRONMENTAL HEALTH DErARTMENT <br /> SERVICE REQUEST <br /> 4C�IUTY <br /> s or Pro ert FACILITY ID# SERVICE REQUEST# <br /> -] <br /> ATOR <br /> CHECK It BILLING AODRE55 <br /> riITEADDRESS ' hl� r� r, IO'k4'J"? C1 <br /> T Street Number t rection Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from 1S_ite Address) <br /> �O (ft�'Y Street Number Street Name <br /> CITYfl STATE ZIP <br /> L <br /> HONE Exr. APN# LAND USE APPLICATION# <br /> ( t 0 SIS <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 tome or my business as identified on this form. <br /> I also certify that I have prepared this applicati and that th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE d FEDERAL Ia <br /> APPLICANT'S SIGNATURE: // DATE: AS <br /> PROPERTY/BUSINESS OWNER O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY proof of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 SOOfl as it is available and at the same time it is provided to rLne Or <br /> my representative. /` n <br /> Yeto <br /> TYPE OF SERVICE REQUESTED: E( t vzj) <br /> COMMENTS: a4-') APR APR 18220115 <br /> t I)\t UVJ SAIV N COUN <br /> REAL-41 UE ENrAt �1' <br /> H <br /> RrMENr <br /> ACCEPTED BY: E YEE#: DATE: S? / <br /> ASSIGNED TO: A/1 EMPLOYEE DATE: (J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I Amount Paid Payment ate `6/S//.S" <br /> Payment Type ✓ Invoice# Check# JCI SS Received By: <br /> I 'v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />