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0 <br /> SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH 010PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> L7® 1et Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE A EXT. APN# LAND USE APPLICATION# <br /> (ao 1) - o o3 o g <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> U � ' v 7 <br /> HOME or MAILING ADDRESS FAX# <br /> t . _ oo ( ) <br /> CITY G STATE ZIP <-�s/ I <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 /> 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,, ST EDERAL IaWs <br /> APPLICANT'S SIGNATURE:: DATE: i�52, ( 7 <br /> PROPERTY/BUSINESS OWNER LEl 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, 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 /> t0 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> QAC 13 <br /> yOFp F,yr 4 <br /> ACCEPTED BY: EMPLOYEE#: -:5-7-7:5 DATE: l / ` <br /> ASSIGNED TO: V EMPLOYEE#: DATE: l�.Z <br /> Date Service Completed (if already completed): SERVICE CooE: lV:iOwP 1 E: �6 <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 />