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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> NMIO NER / O EF TOR r CHECK If BILLING ADDRESS ❑ <br /> �r ,t-e,UC� 3 ` OWN Will III I <br /> FACILITY NAME ( I „1 -* <br /> SITE ADDRESS 1 t (J'� J fw 17, vQ'-i d <br /> treat Milmhar Dion t Siteaf Name 21 -Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE zip <br /> Env APN # LAND USE APPLICATION # <br /> PH��E #1 <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR �- f �, CHECK If BILLING ADDRESS <br /> EXT <br /> Nor P <br /> BUSINESS NAME "' 1 1110 <br /> TL <br /> HOME or MAILING � DRFzS5 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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : d2 J .1DATES ��;Z c � <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT N 6 'ec <br /> It 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 t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> EMPLOYEE #: DATE: <br /> ASSIGNED TO : <br /> Date Service Completed (it already completed): SERVICE CODE: PIES <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> SR FORM (Golden Rod) <br /> EHD 4842-025 <br /> 07/17/08 <br />