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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ER�V11ICEE REQUES <br /> Scat- GQ Fi�F l [`A � <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> D�s�"� �� T <br /> FACT Y NAME <br /> cJG E-I oc>L- <br /> SITE ADDRESS � �Al,t ���a LC, S Z O <br /> L—t-1 C e ber Direction Street Name City Zip 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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> rJ `A� `��`� N� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 7 l PHONE# EXT. <br /> rz c 1_i i q C 7 Ftp 57 z z"z- <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ` / �..�v STALE- /, ZIP 19153: i�- L� <br /> BILLING ACKNOWLEDGEMEN : 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 identifiq"-thii form. <br /> I also certify that I have prepared this applicatierh that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STAT nd EDRA vZs. <br /> APPLICANT'S SIGNATURE: �, / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A� <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tille <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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:' 6 <br /> Fee Amount- Amount Paid t Payment to <br /> Payment Type /S -Invoice# Check# Received By: <br /> EHD 48-02-025�` [�� SR FORM(Golden Rod) <br /> 07/17!08 v , <br /> S <br />