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SAN JOAQUIN �.OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ,/z f tq J` � y� G f CHECK It BILLING ADDRESS <br /> FACILITY NAME_ q q j-, e D f , <br /> SITE ADDRESS 77o 0J4-�� c J <br /> Street Number Direction Street Name_ city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �?v ze�'aN<< <br /> -7700 Street Number _ Street Name. <br /> I CITY )/_`G� STATE ZIP <br /> PHONE#1 EXT. APN# I At, ,USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR nnr" n <br /> CHECK If BILLING ADDRESS <br /> 7777 /1 / "/✓ f/ - <br /> BUSINESS NAME � (' PHONE# EXT. <br /> HOME or(71� ADDRESS _C n �(Ax#r <br /> CITY �J,�0(. /- -2 � (C�r�/ / STATE tai 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 ;his 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, WTE and FEDERAL 12WS. <br /> APPLICANT'S SIGNATURE: rDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER OTHER AUTHORIZED AGENT ❑_T <br /> If APPLICANT is not the BILLING PAR , roof 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It is provided to me Or <br /> my representative. PAY'MIEN7 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOA(aL'Ii%; COUNTY <br /> ENVIFtOPALNTAL <br /> HEALTH DILPARTMENT <br /> ACCEPTED BY: y r EMPLOYEE#: DATE: <br /> ASSIGNED TO: j'�tr- EMPLOYEE#: DATE: <br /> c �P <br /> Date Service Completed (it already completed): I SrRVICE CODE: I PIE: 20 <br /> Fee Amount: — Amount Paid �— Payment Date ✓ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />