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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> • CHECK If BILLING ADDRESS <br /> F wiv NAME <br /> SITE ADDRESS O I' <br /> 2/0K +0Ck40:l <br /> t• 6 <br /> 7 Ire t Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDR S (If Different from Site Address) <br /> )1)0/1 r/—C�&e /- Street Name <br /> CIN STATE ZIP <br /> in <br /> PHONE#t Exi. APN# LAND USE APPLICATION# <br /> —][PHONE#Z Ext. [BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> _BUSINESS NAME PHONE# Ext. <br /> OME 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 HEALTIi 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 SIGNATURF� DATE: q—� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/N1NAG R IdHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of aut rizatio i to sign is required Title <br /> ACiTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS: RFEC, E'VED <br /> SEP -7 2011 <br /> SAN JOACUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ?17Z1 / <br /> ASSIGNED TO: _ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: a`J Amount Paid Payment Date t <br /> Payment Type Invoice# Check# `�7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />