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SAN JOAQUI QOUNTY ENVIRONMENTAL HEALEPARTMENT <br />14 SERVICE REQUEST T T <br />Type of Business or Property / <br />A-ZUte/ <br />FACILITY ID # <br />SERVICE REQUEST # <br />o6 k2-- <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILI Y NAME <br />jL1 DSS D•4�-�' �-�-o <br />SITE <br />l!A'D`DR SS <br />Y I e um er Direction <br />SS. <br />Street Name <br />F'r Ci <br />Fz.Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION ODE <br />CONTRACTOR ACTOR / csFRVIC'F, RVOI JF.STOR <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ?Xj--t- 1 DATE: <br />0 <br />PROPERTY / 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />PAYMENT <br />REGEIVED <br />COMMENTS: <br />MAY 1 8 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid '���� ��-� <br />Payme t Date 0' <br />Payment Type <br />Invoice # <br />Check # !�S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />