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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r s�a��-�6�3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS Gr <br /> FACILITY NAME <br /> SITE ADDRESS �S�{ Dae— nam / O= 015 24 D <br /> Street Number Direction Street Name" Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site <br /> cAddress) <br /> �. l^ <br /> 514-146 AS J4461JE � Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 EXT. APN# LAND USE APPLICATION# <br /> ( i9 (430 -6lb3 D(o <br /> PHONE#T EXT. BOS DISTRATJ_ON CODE <br /> ( ) Val(-]{ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> SAME AS A&tc <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLINGPARTY,proof of authorization to sign is required 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 /> 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. n <br /> TYPE OF SERVICE REQUESTED: SdL/4T2A) ' Hit <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 0822 DATE: 9 i� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 63 <br /> Fee Amount: S#%- Amount Paid ls2 94- Payment Date N <br /> Payment Type �2xInvoice# 31 g q--[Check# Re eive By:b <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />