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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty siness or Property FACILITY ID# SERVICE REQ EST# <br /> �� Fi Dna7� �(�C678a3 <br /> OWNE / PERATOR <br /> t i j�� � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SI E c ItNumber pirectlOn O Street NameCL�-y Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECIUESTOII'�/fL� <br /> LL�� CHECK If BILLING ADDRESS® <br /> BUSINESS NAME ' f PHON <br /> HOME Or MALUNG ADDR $ FAX# <br /> ( &3 <br /> CITY (Z-y 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 /> I also certify that I have prepared this application and that t work t0 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERA ws. <br /> APPLICANT'S SIGNATURE: V DATE: <br /> y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site pS./g� ��r�{p7�mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same tI4�1�EC ID me or <br /> my representative. RECEIVE[) <br /> (� <br /> TYPE OF SERVICE REQUESTED: FOOA T'la{'1 (.-I eL.�— MAY 0 9 Z016 <br /> COMMENTS: ^� 1 ` r <br /> fl���g Od�J l 3 hC SAN NJOAQUIN VIROMENTOALNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �1S EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: SZ 3 PIE: /& <br /> Fee Amount: Amount Paid '-,)(i Payment Date S— 9 <br /> Payment Type- Invoice# Check# - Received By: <br /> EHD 48-02-025 J SR FORM(Golden Rod) <br /> 07/17/08 <br />