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SAN JOAQUIN RUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> • -✓ SERVICE REQUEST . <br /> Type of Business Or Property YR p Y FACILITY ID# SERVICE REQUEST# <br /> S� <br /> OWNER/OPERATOR w ❑ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> sIJEJSS <br /> oyADDRw, <br /> Street Number blrection Street Name Ci Zi Code <br /> HOA4E <br /> /Op/r MAILAG ADDRESS (If Different from Site Address) <br /> ""' �� Street Number Street Name <br /> CITY /47 TE ZIP . <br /> PHONE#1 EXT, APN# / LAND USE APPLICATION# _ <br /> t{� <br /> PH NE EXT• '{� BOS DISTRICT LOCATION CODE <br /> ( lx <br /> CONTRACTOR 1 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S ATE andEIL la <br /> APPLICANT'S SIGNATURE: CDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLiCRNT is not the BILLING P4RYT_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: Pa <br /> COMMENTS: -Z—/, <br /> y` _CEI / <br /> 2 2008 <br /> J0AQl111V LpQ <br /> ACCEPTED BY: EMPLOYEE#: DATE: DFPABTArp <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Wo, cb Amount Paid /� O , Payment Date k9Z. 6 <br /> Payment Type 4 ` ��Invoice# Check# P.6 g Received By: <br /> 1f' <br /> EHD 48-02-025 QA�"'" of SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />