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SAN JOA IN COUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / CHECK if BILLING ADDRESS <br /> 4 ± �! <br /> FACILITY NAME 9 j <br /> SITE ADDRESS <br /> Street Number Direction v� Street Name i/ Zi 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# 10 _ LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATIN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( � <br /> CHECK if BILLING ADDRESSIJ <br /> BUSINESS NAMEy ` PHONE# EXT. <br /> 1i Li r- [ id 0 '7 - ZZ 3 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY (tt 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 I tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar sr STATEand FEDERAL laws <br /> APPLICANT'S SIGNATU <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [/ / ,f' L/ C` 0 <! <br /> ifAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 provided t0 me or <br /> my representative. <br /> PAN N- <br /> TYPE OF SERVICE REQUESTED: e -' , t' '- <br /> EjD <br /> COMMENTS: <br /> t COttN <br /> t4.Ttd'1• <br /> t <br /> ACCEPTED BY: Cfe, <br /> EMPLOYEE#: DATE: —2 <br /> ASSIGNED TO: @ EMPLOYEE M DATE: _ �� %`� ..��® <br /> Date Service Completed (if already completed): SERVICE CODE: r P/E: c <br /> Fee Amount: -ti Amount Paid (, - Payment Date �r <br /> Payment Type C L< Invoice# Check# Received By: <br /> � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />