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SAN JOAQuI.J COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REtQUES-T# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ` r / <br /> ' <br /> y <br /> # b <br /> SITE ADDRESS 4r <br /> Street Number Direction Street Name CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2y (,S ', y n C'Y'4t <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> r <br /> HOME or MAILING ADDRESS _ FAX# <br /> !K(r<s WPI Uva ( ) <br /> CITY STATE ZIP - <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,(hoof 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 asses ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It is me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: CO / <br /> COMMENTS: h4 T <br /> SAIV 1 2011 <br /> HEAT j o ftlE OlJNTy <br /> H QEPm M NTL <br /> ACCEPTED BY: EMPLOYEE#: DATE: _+ <br /> ASSIGNED TO: i EMPLOYEE#: u I(0 )D DATE: ; <br /> Date Service Completed (if already completed): SERVICE CODE: �— �(� PIE: <br /> Fee Amount: 3 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 />