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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH PEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> r� <br /> FACILITY NAME `�n O� � <br /> SITE ADDRESS <br /> 40 C-D r ' v ' � <br /> Street Number Direction I 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#11 EXT. APN# LAND USE APPLICATION# <br /> Qcq) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( <br /> t CHECK If BILLING ADDRESS1 <br /> BUSINESS NAME PHON # ExT. <br /> CJ1l 7— <br /> HOME or MAILING ADDRESS FAX# <br /> 1 88 = - L e ( ) <br /> CITY , �( ; STATE � ZIP'1G-' <br /> BILLING GAACKNOWLEDGEMENT: 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,S ATE and FEDERAL law . <br /> APPLICANT'S SIGNATURE: I DATE: _ <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUT R ED AGENT El <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to ' 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�Ilir�rided to me or <br /> my representative. E <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 2016 <br /> JOAQU1HE EN>r<�E COU, <br /> ACTH DEP,T SENT <br /> ACCEPTED BY: / _ ( EMPLOYEE#:e <br /> : DATE: Al <br /> #: <br /> ASSIGNED TO: lJ`` EMPLOYEE / fE-- DATE: 16� <br /> Date Service Completed (if already completed): SERVICE CODE: a PIE: 1�?) <br /> Fee Amount: iN Amount Pai Payment Date <br /> Payment Type Invoice# Check# Received ByK- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />