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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID#=SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> C <br /> FACILITY NAME 4 <br /> SIT ADDR SS �Y �� � ZipC <br /> �r4J Zi Code <br /> Street Number Direction <br /> Stree N� e �� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE Zip <br /> CITY <br /> V. APN# <br /> 777� LAND USE APPLICATION# <br /> " ) y > ill <br /> BIDS DISTRICT LOCATION CODE <br /> PHONE R Err. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE4UESTOR CHECK if BILLING ADDRESS© <br /> i a <br /> - PHONE# Exr. <br /> BUSINESS NAME l <br /> Z n FAX# <br /> HOME or MAILING ADDRESS tom' � ( I � ( ) <br /> ll I`t STATE ZIP C3 7� <br /> CITY / �t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> acknowledge that all site and/or 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,Stan rds,STA nd FEDERAL laws. <br /> DATE: <br /> APPLICANT'S SIGNATURE: y <br /> PROPERTY/BUSINESS OWNER❑ OPE OR MANAGER ❑ � <br /> OTHER AUTHORIZED AGENT Title <br /> If APPLICANT is not the I RTY proof of authorization to sign is required <br /> applicable,I,the owner or operator of the property located at the <br /> AUTHORIZATION TO RELEASE INFORMATION: When <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 /> COMMENTS: c <br /> - <br /> -h1(w' C1> RECEIVED <br /> SEP 2 4 2009 <br /> SAN JOAGIUIN COON <br /> EMPLOYEE M DATE: H <br /> ACCEPTED <br /> EMPLOYEE#: G� DATE: <br /> ASSIGNED TO: <br /> SERVICE CODE: P I E. 2- 3c9' 1 <br /> Date Service Comp (if already completed): C <br /> Fee AmountCL Amount Paid 3 t� ST Payment Date �j 2� /C): [ <br /> Payment Type <br /> Invoice# Check# 1 I d b ' Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />