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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE I E 'E"Q]UESST <br /> kc-,�hvtlotn FA (7d t`761{3 �P f 6 ) <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADORt:sS <br /> FACILITY NAME <br /> SITE LkDDRESJ <br /> ^�'f StrLet Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATIOIf CODE <br /> ( ) 00 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C' 9 CHECK if BILLING ADDRESS <br /> BUSINESS NAME pH EXT. <br /> HOME Or MAILING ADDRESS / FAX# <br /> ( ) <br /> CITY QfjfAL.�D 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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR / DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY.proof Of author/zafion to sign is required Title <br /> ALITHORIZATION 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time ided to me or <br /> my representative. Y1 <br /> TYPE OF SERVICE REQUESTED: Fr" <br /> COMMENTS: JON J�Amsgva- <br /> q <br /> SA E4V RossA RTMEW <br /> tt�,TH OE' <br /> ACCEPTED BY: Mart',,4, EMPLOYEE#: DATE: <br /> ASSIGNED TO: eEMPLOYEE DATE: - l <br /> Date Service Completed (if already Completed): SERVICE CODE: dG P1 E: G <br /> Fee Amount: F ` Amount Paid 13`�.� Payment Date S 1 �� L'� <br /> Payment Type Invoice# Check# LA Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />