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SAN JOAQUIN 'OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I 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 b S <br /> t�ix✓v" G/ r <br /> Street Number Direction Street Name / � Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ez . APN# LAND USE APPLICATION# <br /> PHONE#2 Ex*. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em <br /> HOME or MAILING D SS FAx# <br /> D ( ) <br /> CITY A STAT ZIP <br /> BILLING ACKNGOC EDGEMENT: 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,ST anBFEDOFAAL laws. <br /> APPLICANT'S SIGNAT �^ DATE: (L/�D� <br /> PROPERTY/BUSINESS E OPERATOR/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, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RE ENS <br /> COMMENTS: <br /> JUN 15 2009 <br /> SAN NJAQUIN <br /> VIRONM COUNTY <br /> HE�Tti DE ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S2L P/E: 3 f( 1/ <br /> Fee Amount: () 1 <br /> Amount Paid �a D O L) I <br /> Payment Date (�/ & C7 <br /> Payment Type �/ Invoice# Check# L�O�Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />