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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l A <br /> OWNER/OPERATORCHECK if BILLING ADDRESS <br /> 6�j I I <br /> FACILITY NAME <br /> ftafim SITE ADDRESS I/1 5 Vv y052rn( �n_n\F gQ"33�0 } <br /> Stlreet Num lber Direction C, Stree N e 'y�JI TTCit��•l. ZiJ�ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name (k <br /> CITY STATE ZIP ff4l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SE VICE REQUESTOR <br /> REQUESTOR ? CHECK If BILLING ADDRESS <br /> FZ10i--7Q8 -- &M <br /> P NE# <br /> r� L EXr. E <br /> BUSINESS NAME G <br /> IL 11, 1-f t 1 <br /> HOME or MAILING ADDRESS \) FAX# <br /> CITY G STATE ZIP 1,1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, op'e'rator 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. I <br /> also certify that I have prepared this application and th he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TE and FEDERA la s. <br /> APPLICANT'S SIGNATURE: DATE:) 2 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANA R ❑ OTHER AUTHORIZED AGENT L�! U� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sign is required l 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 provided t0 me OrLi <br /> my representative. I C <br /> TYPE OF SERVICE REQUESTED: C 1 l Sly r <br /> COMMENTS: <br /> ERk1IR0NMEN'TAL I <br /> DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ^ 4 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 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 />