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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 /> CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME <br /> SITE ADDRESS S j S �� S rPa l• y�.S jam, <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (ifDifferentfrom Site Address) <br /> 'J�� / �-I"7 L� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> (2d6fl FS F-38"• <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FEDERAL-"S. <br /> APPLICANT'S SIGNATURE: ! `f DATE: - J& <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAWT is 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: pAYMEN-f <br /> COMMENTS: <br /> MAY 3 0 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: hi EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid ? Payment Date <br /> Payment Type Invoice# Check# u Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />