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NAN JOAQUIN COUNTY L+'NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ll C lh b 6 <br /> OWNER/OPERATOR, <br /> 1 t /V ' 1 �t%t- � ` CHECK If BILLING ADDRESS <br /> FACILITY NAME j <br /> SITE ADDRESS / L <br /> Street Number ❑ecti n reet Nam Ci (,� Zi ode <br /> HOME or MAILING ADDRESS (If Different from ' e Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �/)(;�r/, <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAMEPHO E# Exr. <br /> � HOME Or MAILING ADDRESS <br /> W, <br /> CITY <br /> CITY STATE <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 applicati and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE nd F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT r /K <br /> IfAPPLiCANT 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 /> PAY <br /> TYPE OF SERVICE REQUESTED: EIVEL <br /> COM <br /> MCENTS: <br /> �j i 'Cl I efd P at JUN 17 2008 <br /> SAN JOAQUIN COUNT! <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: D <br /> ASSIGNED TO: EMPLOYEE#: " DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P 1 E: <br /> Fee Amount: r' Amount Paid �Lt4 e(TD Paymt Date (� 1-7 <br /> Payment Type Invoice# Check# `� g'� Received By: <br /> EHD 48-02-025 SR FORM(Golderi'Rod) <br /> REVISED 11/17/2003 <br />