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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVdNER/OPERATOR \�^\ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME t <br /> Street Number Olre CYI'�t Name •__ Zi Code <br /> QIA��r MAILING ADDRESS (if,Different from Site�ddress) <br /> }\-- Street Number Street Name <br /> CITY /- <br /> STAB P <br /> \ C-) <br /> PHONE#1 ,EXT. APN# LAND USE APPLICATION# <br /> HONE#2 Uv E^'• BOS DISTRICT LOCATION CODE <br /> CQllTR«CTQR SERVICE REQUESTOR <br /> REQUESTOR �/ <br /> C \V q CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,,� C:\ C—) ` ��//y-Mck P 0 # �O� _ T <br /> HOME or MAILING ADDRE ` i FAX# <br /> \�u� J \ ( ) <br /> CITY �CtC �•^ 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 appIi ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar , TAT I and FEDERAL laws. <br /> `,iHPrLICAN II"J SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 0/' OPE 0R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the ILLING 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 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 provox_to me or <br /> my representative. 7► <br /> TYPE OF SERVICE REQUESTED: �� C 1 EIV D <br /> COMMENTS: L 12 20 6 <br /> SA EN IR titN CO NTy <br /> NEALTIf pE ARTA <br /> M NT <br /> ACCEPTED BY: � EMPLOYEE#: DATE: - <br /> ASSIGNED TO: t�� r\ r , EMPLOYEE#: DATE: - <br /> Date Service Completed (if already completed): SERVICE CODE: G P1 E: �D 1 <br /> _, _ t <br /> Fee Amount: 0-,� Amount Pale 3�b D D Payment Date 7 <br /> 2- <br /> Payment Type Invoice# Check# Received By: ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />