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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTINIENT <br /> SERVICE REQUEST <br /> Types of Business or Property FACILITY ID# SERVICE REQU�ESST# <br /> ooc ) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS.� p J 1 qs�—® <br /> St/reet�N/ufii6er Direection treet Name —�' it Zi 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR- a h <br /> CHECK if BILLING ADDRESS <br /> # E <br /> BUSINESS NAME 1(J)� C(iM5 LGk � ( 3 — 7x <br /> HOME Or MAILING ADDRESSiLIX—L W� FAX# // 7 S' <br /> CITY �?, STATE ZIP 6L <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 DEPARTMI;N"r 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 thisapple c ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST, Ez FEDERAL laws. <br /> APPLICANT'S SIGNATURE:-> DATE: /� <br /> PROPERTY/BUSINESS OWNER 11OPERATOR/MANAGER LJ � C�'l.1'.Q�OTHER AUTHORIZED AGEN11-u Ul- <br /> If APPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geoteclmical data and/or enviromnentat/site 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: / .-- <br /> COMMENTS: P MENT <br /> RECEIVED <br /> OCT 0 2 2009 <br /> SAN JOAQUiN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH D ARTM 1�7NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: f0 <br /> ASSIGNED TO:/ l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid 5 j 7 Payment Date l0 p <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />