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SAN aJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEAr In A f <br /> SITEADD SS l �! 1 (1 <br /> 011 S eet Number Direction St rrtA i d <br /> HwEx MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY ZIP <br /> PHONE #1 EUT. APN # LAND USE APPLICATION # <br /> PHON #Z E7t7• BOS DISTRICT LOCATION CODE <br /> t � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME # <br /> HOME or MAILING ADDRESS FAX ft <br /> CITY STAT zip <br /> t <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 japplic tion and that the work to be performed will be done in accordance with all SAN JOAQUII%I <br /> COUNTY Ordinance Codes, Standards, STATE nd FEDERA a s . <br /> APPLICANT ' S SIGNATURE : � � �� DATE : <br /> PROPERTY / BUSINESS OWNER ❑ P OR / MANGER ❑ OTHER AUTHORIZED AGENT <br /> It APPLICANT Is not the BILLING PARTY, proof of authorization to Sign Is reQUtr d Title <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time it IS pro ed to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Cil V 1 <br /> C01,MIENTS : <br /> �9< TH�FP�q O4Nry <br /> IFN <br /> ACCEPTED BY : i 4 / EMPLOYEE # : a DATE: U n <br /> ASSIGNED TO : '1 EMPLOYEE #: 00 3 � DATE : <br /> Z1611 q- <br /> Date Service Completed (if already completed) : SERVICE CODE : P 1 E: � 3v <br /> Fee Amount: Amount Paid x!5 4 Z)Z) Payment Date 7 �r <br /> Payment Type Invoice # Check # Ja � �3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />