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SAN JOAO COUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NER/OPS T�OIR a <br /> �� V t CHECK if BILLING ADDRESS <br /> FACILITY NAME? ti <br /> V <br /> SITE ADDRESS l Q169 b <br /> Street Number Direction Street Name Ci 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# LAND USE APPLICATION# <br /> 06 if `Z L f be . <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f CHECK if BILLING ADDRESS <br /> BUSINESS NAME�` _ G. y PHO,E Ems' <br /> IL <br /> HOME or MAILING ADPRESS f FAX# <br /> CITY { STATE ZIP �LL <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. <br /> APPLICANT'S SIGNATURE: JAA DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 5� ( A ��Y <br /> COMMENTS: I �® <br /> 54.vJoA <br /> qU <br /> HATH <br /> ACCEPTED BY: M�9�0 EMPLOYEE#: DATE: _ 7 <br /> ASSIGNED TO: M c. EMPLOYEE#: DATE: / <br /> Date Service Completed (if already ompleted): SERVICE CODE: EEI'7 <br /> Fee Amount: ,,.� Amount Pai �, (� Payment Date <br /> Payment Type Invoice# Check# �` ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />