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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business <br /> �or Prop�errty� FACILITY ID# SERVICE REQUEST <br /> �,# <br /> ct V <br /> OWNER/OPERATOR <br /> ,A 56'),'�"I-?r.� J �'�G 1� CHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS G 1 C1 IA �� I F AC /�C) ( (� C/�' <br /> f� LJ r�► I� A l <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> I- ' 4&*� C,14- q <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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 FEDER laws. �} <br /> APPLICANT'S SIGNATURE: DATE: I I , <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 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 SERVICE REQUESTED: L �-t _ <br /> COMMENTS: <br /> SUN 'V <br /> ss�N o, 21 ?O <br /> H�4 <br /> ACCEPTED BY: C 6 EMPLOYEE#: DATE: <br /> ASSIGNED TO: _ I EMPLOYEE#: DATE: <br /> r <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E <br /> , <br /> Fee Amount: lS�.�� Amount Pai /Sa Payment Date 2� <br /> Payment Type � Invoice# Check# j bD� Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />