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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> YN <br /> FACILINAME <br /> SITE <br /> � <br /> T <br /> SITE ADDRESS <br /> Street Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I/ ir'[; 1. Street Number Street Name <br /> CITY3 / C STATE ZIPIn JC <br /> e- /7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> VCS / Z <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> (C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMES / PHONE# EXT. <br /> Lir GS Q / CLJ C� 1 YJ� (>l YS 9--7 <br /> HOME Or MAILING ADDRESS FAX# <br /> If - i &—L./ L ( ) <br /> CITY PC,.0 ^ I7 iC- STATE ZIP 3/ <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,/Si_�/E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 6j�C Q3) DATE: b3,)3/ <br /> PROPERTY BUSINESS OWNER❑ OPERATOR I MANAGER © OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 provided to me Or <br /> my representative. / P <br /> TYPE OF SERVICE REQUESTED: (�� �n5u : "rUh RECE <br /> COMMENTS: Cc�Y /Irl ;• MAR 31 2- <br /> 7 SANjEI JOAQUIN COUNTY <br /> HEALTH pVVIR�Aq AIL <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: •YZ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6 PIE: /I_Q <br /> Fee Amount: I Amount Pafd /30e O D Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 1 <br />