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Jn hal smn '411011 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> y J✓� / ` /� /��lC CHECK If BILLING ADDRESS <br /> FACILITY NAME r(SITE ADDRESS <br /> 33 Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1/ 9 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#T ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // <br /> 'A CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 0 X61 - 16Z6 <br /> HOME or MAILING ADDRESS FAX# <br /> -A <br /> CITY 'A STATE �i/] ZIP f) jo <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 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: zg �� -1 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 io n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS provi N� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ' 0 �® <br /> COMMENTS: SAN <br /> �/1 I EAIV,AQUi/V <br /> � <br /> Lcl1 ,--)L I �� h�LThpEMENTJivTy <br /> I Y � RrMNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 0 - 19 <br /> ASSIGNED TO: EMPLOYEE#: DATE: L4 _ ' OI _ 17 <br /> Date Service Completed (if already completed): ILI SERVICE CODE: //Yn PIE: L-).3/ 02, <br /> Fee Amount: / Amount Pal r/J - Payment Date `T <br /> Payment Type IJGC' Invoice# Check# Recei d By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />