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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR CHECK If BILLING ADDRESS <br /> T <br /> FACILITY NAME T <br /> SITE ADDRESS /� / <br /> Street Number Direction E rest Name Ci Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> PHONE #2 EXr• BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE Ems' <br /> BUSINESS NAME ( nn:: D . <br /> HOME Or MAILING ADD ESS AX # <br /> CITY STATE <br /> BILLING ACKN WLEDGEMENT: 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, Standar , STATE and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE : ' <br /> PROPERTY / BUSINESS OWNER ❑ OP TOR / NAGER ❑ 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 to me or <br /> ed <br /> my representative . T <br /> (' RECEIV D <br /> TYPE OF SERVICE REQUESTEM <br /> COMMENTS: AM 13 � 2 ! <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTN ENT <br /> ACCEPTED BY: � ��V� EMPLOYEE #: DATE: / �J <br /> ASSIGNED TO: �� il, EMPLOYEE #: DATE: 0/ / ( <br /> Date Service Completed (if already completed) : SERVICE CODE: lepjjft- , cl Fs PIE : ✓ ) o <br /> Fee Amount: , &0 Amount Paid Payment Date 2D <br /> Payment Type Invoice # Check # Received By: <br /> SR FORM (Golden Rod ) <br /> EHD 48-02-025 <br /> 07/17/08 <br />