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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> Res Tx- Lt va Sib-7-1''49 <br /> OWN R I OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAM ' ` I <br /> SITE ADDRESS J{(� 5 ��(]� 1 <br /> Street Number Direction Vf/ Celt Name!'- ^o ZiCade <br /> MEOf MAILING <br /> /!ADDRESS (if Different from Site Address) � <br /> Street Number Street Name <br /> CI STAT � ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHDNE rl2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> fiiN <br /> BVSINE NA+�E PHONE# Exr- <br /> U , �d <br /> HOME or MAILIN t DQRES� rb� FAX# <br />} CITY V STATE C' 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 /> also certify that I have prepared this application a d ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST ERAL laws. <br /> I <br /> APPLICANT'S SIGNATURE: DATE: �� � v •� <br /> PROPERTY I BUSINESS OWNER OC OPERAT 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 to at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site ass s on <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it �� Or <br /> my representative. 4J <br /> TYPE OF SERVICE REQUESTED: `� 2 <br /> COMMENTS: AN JOAQUI <br /> N4NVI A COU <br /> �rY <br /> Nr <br /> ACCEPTED BY: V v1 D I EMPLOYEE#: DATE: <br /> ASSIGNED TO: ci EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: L 11: V f <br /> Fee Amount: -All 00 1Amount Paid i�[ DZ) I Payment Date <br /> Payment Type / Invoice# / Check# Receiked By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />