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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 /> ., i CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME J(�� <br /> SIT E_ADDRESSP�� ^P—� I� 7 1` <br /> L] Street Number Direction StrName C ode <br /> HOMEorMAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY / � STATE ZIPS jZL <br /> n� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> I also certify that I have prepared this application and that the work to b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes„Standards TE and FEDERAL laws. ( <br /> APPLICANT'S SIGNATU X- ,� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 <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: <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> f0 �►ws'L �aiyvra ::�, ,,�, NOV 2 1 2007 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: EALTH D AL <br /> E <br /> ASSIGNED TO: EMPLOYEE#: 5,2 <br /> DATE: let" <br /> Date Service Completed (if already completed): SERVICE CODE: 3/ <br /> Fee Amount: Amount Paid (� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />