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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 7 ( Street Number I Dirtion Street Name Cit 1 1 Z Cod <br /> HOME or MAILING ADDRESS (If Different from Site ddress) `r <br /> v\/ �� ( Street Number Street Name <br /> i <br /> TY 1 rC� C STATE ZIP <br /> i <br /> PHONE#1 EXT. qPN# LAND USE APPLICATION# <br /> 12 _3C, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSQ <br /> USINESS NAME ((((1111 PHONE# Exr. <br /> or MAILING ADDRESS q 1 FAX# <br /> L <br /> CITY STATE C �1 ZIP Cf <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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, STATEa d EDERAjaw,. <br /> APPLICANT'S SIGNATURE: DATE: 1 � 11 <br /> � <br /> PROPERTY/BUSINESS OWNER EYOPERATOR/MANA ER ❑ 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, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �— C C <br /> 2 -SPAYMENT <br /> COMMENTS: / x �1 S RECEIVED <br /> JUL 2 8 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: y( DATE: 1101— <br /> ASSIGNED T r-t) — J C- EMPLOYEE#: (( /� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E, r7 I <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# F�eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />