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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAC ICLIITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> f,tJ � 015336 <br /> treet Number Direction Street Name Cit Zi Code <br /> H DDRESS (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 DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 9 <br /> I CHECK If BILLING ADDRESS D <br /> BUSINESS NAME [CPHONE s 2- 3 <br /> HOME Or MAILING ADDRESSr� FaX#�) 2 <br /> CITY STATE ZIP ��3 30 <br /> BILLING ACKNOWLEDGEMEN : 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 <br /> or 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, STAT and FEDE L laws. <br /> 7 / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER El OR/MANAGERPf <br /> OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL G 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: S J` ED <br /> COMMENTS: V Art( 2012 <br /> SAN JOAQUIN CD.u" <br /> EMYIRONMEIITAL <br /> HEALTH DEPA,RTVE?I, <br /> ACCEPTED BY: EMPLOYEE#: DATE: ` ^0 <br /> ASSIGNED TO: C/' EMPLOYEE#: C ' ' DATE: �i C_ <br /> Date Service Completed (if already complle_ted): SERVICE CODE: S2 P/E: 7 <br /> Fee Amount: 6,P °Z 0 Amount Paid 15 t' cat Payment Date l� � t Z-- <br /> Payment Type Invoice# Check# ��� Received By: 2e,f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />