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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ' RARTMENT <br /> SERVICE REQUESTu EB _i 20'N <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> ENVIR NMENTAL HEALTH <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESSew <br /> ■r � <br /> FACILITY N <br /> SITE ADDRESS <br /> (� 57 Stre <br /> yet Number Direction S eet Name Cid Zi Code ` <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> P . . gA", ,,. <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # u <br /> PHONE #2 ExT• BOS DISTRICT e 10 CDD�019 <br /> ( ) 6 /G+ <br /> I�If�O <br /> CONTRACTOR SERVICE REQ �JESTOR ��L ENCOUN rY <br /> rrr� <br /> REQUESTOR q CHECK if BILLING ADDRESS <br /> BUSINESS NAME a� PHONE # EXT, <br /> met a14 CP � 06 5 <br /> HOME Or w1lING A4D,R7 SS � � � 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 /> 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, Standars, STATE and FE AL laws . <br /> APPLICANT ' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof f 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 provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Lf-e9P 7 � w '&� 6::.3t� OaI <br /> Ile <br /> COMMENTS: /� /� A f Ve1/ p AJQ � e <br /> OweO ,y 6WJ <br /> �� 5 36� s✓ i d �� � ' <br /> ACCEPTED BY : ��9 n EMPLOYEE #: / � �� I DATE : 1 <br /> ASSIGNED TO : EMPLOYEE #: < l! ``� DATE : 1 j <br /> Date Service Completed ( if already Completed : SERVICE CODE : f I P / E : <br /> Fee Amount: Amount Paid 54IS67v �)� Payment Date <br /> Payment Type Invoice # Check # /D Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />