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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> l <br /> SITE ADDRESS �• - , <br /> Street Number Direction - Street Name city Zip 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 /> ) <br /> PHONE i/2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMET / PHONEEXT. <br /> .T <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 ide n this form. <br /> also certify that I have prepareAthisap t' n a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand E RAL laws. <br /> APPLICANT`S SIGNATUREDATE:PROPERTY/BUSINESS OWNER�� OR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7'irtr <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 assessor IrDlption <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the same time It IS e t `Qr'� <br /> my representative. `+�ll� <br /> TYPE OF SERVICE REQUESTED: �. - A <br /> COMMENTS: Sq/y� <br /> �l DEPMENTA[ <br /> ARTiyFNT <br /> ACCEPTED BY: ` } EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , P/E: <br /> Fee Amount: a Amount Paid-y? Jit i� Payment Date <br /> 1 l <br /> Payment Type ''1: Invoice# Check# / ' 7 i Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />