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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VERVICE REQUEST# <br /> OWNER/OPERATOR ` ,J / CHECK If BILLING ADDRESS❑ <br /> \ G lY\ <br /> FACILITY NAME <br /> / 1 `P <br /> SITE ADDRESS nL1//1 2J <br /> Street Number Direction l ( Name 150'0 <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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J <br /> "U (/l�I?4� 6� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME d C ( PHONE# EXT. <br /> r519(2 <br /> HOME Or MAILING ADDRESS FAX# <br /> 7 a ( ) <br /> CITY STATE jn ZIP G} r D ' <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 t rc to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and F ESAL I-- <br /> -7 // <br /> APPLICANT'S SIGNATURE: (� DATE: 7 <br /> I PROPERTY/BUSINESS OWNER❑ OP ATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS not the BILLING PARTY,proof f authorization to sign is required Time <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 tlmPNOVlded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: CONIe �� <br /> COMMENTS: Y <br /> RFHO�N� <br /> TMENr <br /> ACCEPTED BY: � EMPLOYEE#: —7 — <br /> DATE: 1749 <br /> ASSIGNED TO: EMPLOYEE#: ,7O!A DATE: <br /> Date Service Completed (if already completed): /I/�q11 SERVICE CODE: ( � P/E: -� `h v <br /> Fee Amount: �L 00 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By:� <br /> a <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />