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C) IA <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �\ �r CHECK if BILLING ADDRESS <br /> �ctCC�G <br /> FACILITY NAME \ <br /> SITE ADDRESS <br /> � }S3�Cj <br /> \�\L A Street Number Direction Street Name Cit ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Z (=; Street Number Street Name <br /> CITY STATE ZIP <br /> EM(Dt'-Z A <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST R n\ <br /> �M A L- J I N� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PFIONE# EXT. <br /> 0�;CC �Ea�T tv4�S . NC S\o-3`b�-' 6 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY M O fl T STATE <-A Ll <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 FED AL laws. <br /> APPLICANT'S SIGNATURE: yck`-.,` DATE: <br /> PROPERTY I BUSINESS OWNER® OPERATOR I MANAGER OTHER AUTHORIZED AGENT ❑ <br /> I{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. PAYMEN <br /> TYPE OF SERVICE REQUESTED: It } RECEIVE <br /> COMMENTS: P,GP,�t� d 4 201 <br /> SAN P JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ �I- "- <br /> ASSIGNED TO: EMPLOYEE#: DATE: 0� <br /> Date Service Completed (if already completed): SERVICE CODE: Z 77 PIE: <br /> Fee Amount: Amount Paid Payment Date (IZ� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />