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SAN JOAQU OUNTY ENVIRONMtNTAL HEALTH PARTMENT <br /> of SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 144446: 4�,MeAA& <br /> b3 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> i <br /> FA TY NAME <br /> SITE ADDRESS .. <br /> Street Number Direction Street Name Ci ` Zi C•od4Ge1 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> a7-)W Number treat Name <br /> CITY STATE ZIP <br /> _�!✓yfi <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQLJESTOR ^ <br /> CHECK if BILLING ADDRESS L�1 <br /> BU�SiNESS III �$ PHONE# EXT• <br /> HOME or MAILING AD ESS FAX# <br /> CITY STATE ZIP L <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 <br /> or 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 F E-94L laws. <br /> APPLICANT'S SIGNATURE: DATE:� �/J B e <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT "�f,�� <br /> IfAPPL/CANT 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 /> T <br /> COMMENTS: <br /> JUL 10 2008 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2-L DATE: <br /> Date Service Completed (if already completed): SERMCE CODE: P 1 E <br /> Fee Amount: 71 Amount Paid a �� Payment Date + g <br /> Payment Type 101— Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />