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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # S RVICE REQUEST # <br /> OWNER / OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME �^ l H <br /> SITE ADDRESS 5� � 1 I 1 2 l rlG� q !; 3 ` 1 6 <br /> Street Number Direction lSI �/ 'S'trCe�et Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (' L n � <br /> Z� Sit t Number 1� i —r Stree Name <br /> CITY <br /> y�— / STATE � <br /> + ZIP �} I J 13 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> (oj2 S � 1 - III 1 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> dui Ll1r <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> HOME or MAILING ADDRESS FAX # <br /> CITY 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 I have prepared this application and that the performed will be donen accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDE L laws . JI <br /> APPLICANT' S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titl <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 environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to me or <br /> my representative . c <br /> TYPE OF SERVICE REQUESTED : ST <br /> COMMENTS : <br /> �vv �gR ' S ?01 <br /> HIRpNM COVH9 <br /> � CEA��gC fY <br /> ACCEPTED BY: fv\ . � EMPLOYEE # : Ct DATE : <br /> 3 � 5 - 2p1� <br /> ASSIGNED TO : Z � EMPLOYEE # : DATE : 3 -1 , _ZO I c? <br /> Date Service Completed ( If already Completed ) : SERVICE CODE : � � PIE : <br /> 3 <br /> Fee Amount: 151 Amount Pal /52 . D � Payment Date <br /> Payment Type Invoice # Check # � Receiv d By : <br /> EHD 48-02-025 ` / SR FORM (Golden Rod) <br /> 07/17/08 <br />