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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING bbR <br /> FACILITY NAME <br /> SITE ADDR SS [5je- I1Ili �//Street Number bart "1 lei- e a e' + I C <br /> HOME or MAILING ADDRESS (If Different from Site Address) S 1- <br /> Street Number a Na <br /> Cin • rE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> Rf=QUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME r.JI l PHONE 2]22I ExT, <br /> HOME or MAILING ADDRESS I FAx# <br /> CITY i ' 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 /> I also certify that 1 have prepared this application and that the work to be perfor d ill bed a in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S s• <br /> APPLICANT'S SIGNATURE: Dq E: <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER © OTH R A HORtZED A NT13 <br /> If APPucarvr is not the BILLING PARTY.proof of authorizatlo o sign Is required Tfile <br /> AUTHORIZATION 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 environme a gI r vnt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the AW ided to me or <br /> my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTW-W <br /> ACCEPTED BY: S e_ EMPLOYEE#: (903L, DATE: I/R/M <br /> ASSIGNED TO: EMPLOYEE M 3 DATE: 1' :7/ <br /> Date Service Completed (if already completed): SERVICE CODE: (�/ I PIE: <br /> Fee Amount: Li t�Z () Amount Paid 1S2. Payment Date L -1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />