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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ;FACILITY <br /> �03ZS a2Oo 7/ 3ctC� <br /> OWNER/O TOR <br /> / CHECK If BILLING ADDRESS <br /> � FACILIr(NAME <br /> C - <br /> ITE/gADDR/ESS <br /> r (� C 1 Street Number Direotmo Str fne "' CiN �Zir CC <br /> ME Or NAILING ADDRESS (If Different m Site Address) <br /> / Street Number T'J' Slreel Name `� <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 1, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BIDING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING& DRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or 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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes, Standards, STA nd FEDE laws. <br /> APPLICANT'S SIGNATURE: r < DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required 7fNc <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. p p <br /> TYPE OF SERVICE REQUESTED: Su-�, - I'AYME <br /> NT <br /> COMMENTS: EIVE® <br /> JAN 16 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED BY: /jjn�r - 1IEMPLOYEE#: DATE: / // I j <br /> ASSIGNED TO: f !!�� � EMPLOYEE Sr': DATE: G <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: ' oust Paid />O ,_ Payment Date <br /> Payment Typet <br /> 11 voice Checlk# Received By: <br /> EHD 48-02-02 <br /> 07/17/08 SR FORIA(Golden Rod) <br />