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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propert FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> �r- VI CHECK if BILLING ADDRESS E] <br /> � � oLd� 4C, 6l � A <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �I StreeTTt Number Direction ( Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE IQUESTOR <br /> REQUESTOR <br /> .j ✓+ CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT, <br /> C �' ow �G �S l (v ' Coal. Z <br /> HOME or MAILING ADDRESSFAx #O \ <br /> "1� W �/�i �W V 5� � ( ) <br /> CITY �' STATE � 0� ZIP <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agentofsame , <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, SZTATE D laws . <br /> APPLICANT' S SIGNATURE : DATE : Z <br /> PROPERTY I BUSINESS OWNER 13OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ), v ` OOH L �^�P-�Y <br /> If APPLICANT is not the BILLING PARTY, proof of authorization t0 sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the e <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 : RECEIVED <br /> AUG 03 202 <br /> SAN JOAQUIN COUNT/ <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ` C �� �t,, �� t� EMPLOYEE # : DATE:ASSIGNED TO : ' C�t � EMPLOYEE #: DATE:tf L9 <br /> Date Service Completed (if already completed) : SERVICE CODE: ' If: 2 <br /> Fee Amount : Amount Paid 4Payment Date <br /> Payment Type Invoice # Check # 6 � Received By: <br /> EHD 48-02-025 ] �j SR FORM (Golden Rod) <br /> 07/17/08 0 ' / 1 6s�o �a L 4/ / �D 2/ <br />