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SAN JOAQUIN <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST it _ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -52 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME P,l <br /> -� <br /> SITE ADDRESS Street Number SteetoNam�e City <br /> S' <br /> Zi Code <br /> /HOME <br /> or MAILING ADDRESS If Different from Site Address) <br /> t V✓�i � 1�` Streettuber Street Name <br /> r CITY STATE ZIP <br /> d (7, C �l` <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> Q2 ) Y7 3-6,6'-T <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <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 Standards STATE and FEDERAL laws. f` <br /> APPLICANT'S SIGNATURE: �.`.` DATE:ti <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAR — T CITHORIZED AGENT <br /> GE ❑ <br /> If 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 <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: PAY <br /> COMMENTS: <br /> ECEIVED <br /> SEN - 2 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: Z DATE: <br /> ASSIGNED TO: S EMPLOYEE#: 46�67 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid S e W Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />