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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN PE / <br /> CHECK if BILLING ADORE55E] <br /> FACILITY NAME,/^ <br /> L—�/ U <br /> SITE ADDRESS / <br /> Slreet Nu Direction treat 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 EXT. APN# LAND USE APPLICATION# <br /> (fid 532 -61a,:::- <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> . CHECK If BILLING ADORES <br /> <J^ S w <br /> PHONE# Ex. <br /> BUSINESS AM &/ 6 <br /> 5 Z,c— <br /> HOME or MAILING AD DRESSFAX# <br /> CITY TATE ZIP �lQ <br /> L eLa�G' <br /> BILLING ACIGNOWLEDGEMENT: 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 associate wt Ct <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared I. p'p1TLat'onttQ hat the k to be performed will be done in accordance with all SAN JOAQU!>! <br /> COUNTI' Ordinance Codes,St anis, STATE FE ERA a S. <br /> APPLICANT'S SIGNAT !r�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER0 OTHER Ai THORIZED AGENT CG <br /> If APPueeNT is not the BILLING PARTY proof of authorization to sign is required rule <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 environmentaUsite 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: PAYMENT <br /> COMMENTS: <br /> FxtrhW�-W APR 17 1009 <br /> SAN JOAQUIN COUNTY <br /> HEALT}{RENTAIL <br /> DEPARTTMENT <br /> ACCEPTED BY' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed !if al. ady completed): SERVICE CODE: s"LL PIE: <br /> Fee Amount: �. r" Amount Paid Payment Date -� <br /> Payment Type ✓ invoice# o� Check# 3 `3 R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />