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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Jel c o S � C � 5 3 7 - <br /> OWNER / OPERATOR � /$ CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> SITE ADDRESS l W b T l G`� <br /> �-_ <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number St et Na}✓me <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # "Y <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR rul CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # Ems' <br /> HOME or MAILING ADDRESS FAX # <br /> CITY <br /> /R STATE rA ZIP q ,nl <br /> 9 <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 /> 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 Alaws , r <br /> APPLICANT ' S SIGNATURE : �`Lt .y l � �¢ d, �1 ' r `[ � L DATE : JI <br /> PROPERTY / BUSINESS OWNER ❑ 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 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 . Ir 414� <br /> TYPE OF SERVICE REQUESTED : / }� DRan CAL&L et%% ftr 4p4 <br /> I <br /> COMMENTS : J F <br /> U <br /> N <br /> 84 0 <br /> NF N �Oq <br /> A � rN o pqR M CNT <br /> F <br /> ACCEPTED BY : S-{�f' �� � EMPLOYEE # : DATE : <br /> ASSIGNED TO : C (/UIQ EMPLOYEE # : DATE: 1�5/ 4 yL, <br /> Date Service Completed (if already completed ) : s SERVICE CODE : 1�� i2��i` PIE :� Qq <br /> Fee Amount : ' 2 Amount PaidlS�t � V Payment Date (Q 7 ZZ <br /> Payment Type Invoice # Check # 2S Recelved By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />