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SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 60FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Amts / 1 ^ 1 , oor! �4 t �/)rg 1 y <br /> SITE ADDRESS (�/IY Y'(.{t( .fi G J <br /> Sfy <br /> Street Number Direction reef Name T C I, <br /> Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Addres ) <br /> Street Number <br /> CITY � $TATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# '�/ ✓/ <br /> 0!� ) 5 f; -46 C3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> S CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,\l EXT. <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNO LEDGEMENT: 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, STATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �y� S z,�C DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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 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 provlded.tQ_me Or <br /> my representative. qq 4's,g' <br /> TYPE OF SERVICE REQUESTED: e �t �6e '°Vi <br /> COMMENTS: -14N <br /> �II �'Rf 'J <br /> ti FNV� I Q(�jV W <br /> E94Ty�� CO� ,Y <br /> MF/V <br /> ACCEPTED BY: Lro - EMPLOYEE#: I DATE: -/2 I G/ <br /> ASSIGNED TO: v l /� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /1l i PIE: I <br /> Fee Amount: (I 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 />