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Facility Name <br />Site Address <br />Direction <br />2Z1Z <br />StateCity <br />Ext.APN# <br />Location CodeBOS DistrictExt. <br />Requestor <br />Business Name <br />ZipStateCity <br />Type of Service Requested: <br />Comments: <br />Employee#:Accepted By: <br />Assigned to: <br />Invoice # <br />SR FORM (Golden Rod) <br />Check #^5-]^*^^ <br />EHD 48-02-025 <br />07/17/08 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY id # <br />Ext. <br />G?/ <br />Zip Code <br />Employee#: <br />Service Code: <br />Payment Date <br />________Street Name <br />Zlp <br />Land Use Application # <br />Phone #2 <br />(__) <br />City <br />f STATE ZA Zip -7 z'a ZZ' <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 />I 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: Y <br />Check if Billing Address <br />Check if Billing Address D <br />- <br />r /^SERVICE REQUEST # <br />CONTRACTOR / SERVICE REQUESTOR <br />Home or Mailing Address 2 2^2 <br />Fee Amount: <br />Payment Type k . <br />Owner / Operator , , ---> <br />5 fa n M C ■_____ <br />$ '/sth uw 2 2 2 3 <br />facets <br />Street Nanin <br />___________________________________________ Date: <br />Property / Business Owner Operator/Manager Other Authorized Agent <br />/f Appl/cant 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.- <br />Type of Business or Property <br />Date Service Completed (if already completed): <br />Amount Paid <br />^Oig <br />------- --------------- <br />Date: <br />| P/E: ll^Ql <br />Received By: <br />Phone # <br />(^/AF <br />Fax# <br />(___) <br />_______Street Number <br />Home or Mailing Address (if Different from site Address) <br />PO 60* 27 <17. Street Number <br />Phone #1 <br />( )