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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 r CHECK If BILLING ADDRESS❑ <br /> FACIUTY NAME / <br /> SITEADDRESS <br /> Street Number Direct on re Na City <br /> Z e <br /> HOME Or MAIUNG ADDRESS (if Different from Site Address) <br /> Street Number St Nama <br /> CITY STATE ZIP <br /> PHONE / Em APN# � LAND USE APPLICATION# <br /> 9 - i 3--100 - n^ <br /> PHONE — '/ BOS DISTRICT LOCATION ODE <br /> by <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BI WNG ADDRESS <br /> BUSINESS NAMEPHONE Exr' <br /> O � i <br /> HOME or MAILING ADDRESS FA%# <br /> zZ ( 1 <br /> CITY STATE A ZIP T <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 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 ap tion and that the w4,to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TE and FEP14law . <br /> APPLICANT'S SIGNAT DATE: ;71 I _� <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 <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: r <br /> COMMENTS: 6 <br /> /y/48 <br /> Pe+A1 JUL 3 1 tu08 <br /> /Y//y r= i2a SAN JOAQUIN COUNTY. <br /> "EALTHRGOEPARNTAL <br /> TME <br /> TAfENr . <br /> ACCEPTED BY: EMPLOYEE#: 3�p DATE: ' <br /> ASSIGNED TO: 0 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed); SERVICE CODE: CJ'L7� PIE:4201 <br /> Fee Amount: N Amount Paid 1 l�^ Payment Date Yf 3 I IS-Z <br /> Payment Type Invoice# Check# �ZL $ Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />