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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1,11 <br /> OWNER If OPERAT R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ( <br /> SITE ADDRESS !_ <br /> / B6d6 <br /> Street Number Direction <br /> HOME Or 9AILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> IZper 2 276a CX51 <br /> PHONE#2 ^? ExT. BOS DIST�IC'T;1, LOCATION(CODE <br /> V' 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME6r / PHONE Ezr. <br /> HOME or MAILING ADD S / FAX# <br /> CITY LT� �� STATE0� 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST TE d FEDEf L laws. <br /> APPLICANT'S SIGNATURE: �i DATE: <br /> PROPERTY/BUSINESS OWNER[3 rty�� i OPERATOR/MANAGER ICJ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property local �t the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses eftir, n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS T <br /> my representative. ' <br /> TYPE OF SERVICE REQUESTED: { Ve-PI(cj On R <br /> COMMENTS: <br /> t y ��DUINOOU <br /> s-1Q l-i onah y 'C..Cl rA-. OF M V <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: .� EMPLOYEE#: DATE: . / Q <br /> Date Service Completed (if already completed): SERVICE CODE: O to PIE: ' t�� <br /> Fee Amount: I�Z— Amount Paid 45-:2,D6 Payment Date <br /> Payment Type �f✓� Invoice# Check# <br /> Recei ed By: <br /> EHD 48-02-025 ld <br /> G <br /> SR FORM(Golden Rod <br /> 07/17/08 ( ) <br />