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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 I OPERATOR CHECK If BILLING ADDRESSI� <br /> IJ urtvi�'U'0' In <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Numher Direction Street Name Cil Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> EXT• APN # LAND USE APPLICATION # <br /> PHONE #1 <br /> PHONE #TEXT• SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> IM 03 � w jCLLA <br /> PHON # ExT' <br /> BUSINESS NAME Dt i ``c C� �� L� u �t 4' 3 <br /> HOME or MAILING ADDR S J FAX <br /> CITYC' "k � Q 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 IaWS . <br /> APPLICANT ' S SIGNATURE : ItR( MOOL �,I.uV DATE : h. `( <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT OLCL" L&Lme t <br /> If APPLICANT IS not the BILLING PARTY, 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 . Q <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: Wee V <br /> JUN 6 2011 <br /> HAA' JOA N oN/N CQ��y <br /> EALTHDE TA <br /> ACCEPTED BY: \ �� , EMPLOYEE #: DATE : J �f <br /> ASSIGNED TO : 607 EMPLOYEE # : DATE: V I <br /> Date Service Completed (if already completed) : SERVICE CODE: / GJSi 2 !a PIES 2 �' <br /> Fee Amount: - � OO Amount Paid � , Z)o Payment Date ! /� <br /> Payment TypeVieInvoice # Check # 12,, 1,63R ,3UReceived By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />