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SAN JOAQUIN 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 NAME <br /> SITE ADDRESS <br /> Stree[Number I Direction Street Name Ci Zi Catle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE . ZIP fir, <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (20 ) 6'0-50� �/o <br /> PHONE#2 / // EXT. BIDS DISTRICT LOCATION CODE <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I <br /> ( J PROPERTY/BUSINESS OWNER PERATOR/MANAGER El OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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 assessmenformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It i5 available and at the same time It Is proVl tDo <br /> r <br /> my representative. .-/oL' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 03 <br /> RNfq�OU/ ?O� <br /> �/OF qR> N <br /> MFNT <br /> ACCEPTED BY: rn EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: —� <br /> Date Service Completed (if already completed): SERVICE CODE: I P/E:C40 63 <br /> Fee Amount: �� _ Amount Paid /S-bD Payment Date 3 <br /> Payment Type C Invoice# Check# Reeved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />