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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'Q <br /> OWNER/OPERAT <br /> Iqn O CHECK If BILLINGADDRESS <br /> FACILITY NAezov <br /> L L - <br /> SITE ADDRESS f��Itiz <br /> Street Number Direction "� "'r✓ 'Street Namne �� �JZf Catle� <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 /> PHONE#2 ExT BOS DISTR b� ,_ LoCATI94 CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Hrn <br /> CHECK If BILLING AODRESSE] <br /> BUSINESS NAME - PHONE# s // EXT. <br /> HOME Or MAILING ADDRf SS FA%# <br /> ,PQ Li L14 ( ) <br /> CITY STATE c4q <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 /> also certify that I have prepared this applic tion and this th wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standarcls, r d FEDERA law . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 14 OPE4rOR/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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as It IS available and at the same time It Is provided to me Or <br /> my representative. PAXMPNT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> � <br /> 1/eJ1 JAN 0 3 20% <br /> ` 'G V-611 e- 0 O �W SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIEE: I O� <br /> Fee Amount: I rJ-Z- ' Amount Paid cJ—a Payment Date 3 <br /> Payment Type C,�-- Invoice# Check# Received By:' -- <br /> LIA <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />