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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE RE UEST # <br /> C 0C' � � � G� � <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS r <br /> I qw)k� <br /> s <br /> FACILITY NAME <br /> SITE ADDRESS 1 � `� _ <br /> 5tr'2€t1VQmber Direction v tre1 a e Ci ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) :��,-N�imt�t 1 � �I <br /> S re reet <br /> CITY TE ZIP <br /> PHONE #1 Exrm APN # LAND USE APPLICATION # <br /> AAM <br /> PHONE #2., Ext. BOS DISTRICT LOCATjON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` \ \ \ CHECK if BILLING ADDRESS ❑ <br /> BUSINESS NAME PHONEf r E <br /> (26 C� <br /> HOME or MAILING ADDRESS © FAX # <br /> VAcci <br /> ( ) <br /> CITY ` TATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1 , 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 /> 1 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, STA and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE : <br /> PROPERTY / 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 , 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 time it Is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED ; <br /> COMMENTS: Lx t749 <br /> sq y�04 <br /> Zo,VjryB <br /> ACCEPTED BY: k , rI EMPLOYEE #: DATE : <br /> ASSIGNED TO : A t A s I "� clt r EMPLOYEE #: DATE : <br /> Date Service Completed (if already completed) : � ( J�. Ir� L f� � 'L SERVICE CODE: PIE : 7 <br /> i G <br /> Fee Amount : G+ + Amount Pa' l � � d� Payment Date 3 <br /> Payment Type Invoice # Check # /(�(�3 Recei d By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />