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` SAN JOAQU40 IAUNTY ENVIRONMENTAL HEALTIV <br /> ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> os �� <br /> OWNER/OPERATOR <br /> I�A E' � r CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME �V� <br /> SITEADDRESS <br /> Street Number Direction treet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -k r CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE.# 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 <br /> or 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1:q DATE: 2--2—(C,� <br /> PROPERTY/BUSINESS OWNER 1:3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �t��-(:+ 1\1k(L4q(kt` - — <br /> IfAPPLICANT 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 <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: PAYM <br /> COMMENTS: <br /> JUN 2 2 2009 <br /> SAN JOAQUIN <br /> COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 3)S, Amount Paid 3�S �� PaymentDate 6 a O <br /> Payment Type Invoice# Check# �j�J (f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />