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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> � %eor 9 2� FIL <br /> OWNER / OPERATOR _ . �11 <br /> � y (; n � l _ I/ qtf HECK if BILLING ADDRESS <br /> FACILITY NAME Zti 11 11 1111` v � i f/� <br /> tM/L <br /> SITE ADDRESS �/ <br /> Street Number Direction Street Name Cit '! ZI Code /io <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESSED <br /> BUSINESS NAME 1 PHONE # EXT• <br /> HOME Or MAILING ADDRESS r- / FAX It <br /> CITY �� ` STATE ZIP <br /> BILLING ACKNOWL DGEMENT: 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 laws. <br /> APPLICANT'S SIGNATURE: DATE : <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tile <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 environmentallsite assessment information <br /> t0 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. t <br /> ++CERTIFY PLLD VEEDER ROOT PRESSURIZED LINE LEAK DETECTOR <br /> TYPE OF SERVICE REQUESTED . 1 <br /> COMMENTS : RECEIVED <br /> FEB 0 7 2. 023 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE # : DATE: <br /> ASSIGNED TO : EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />