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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 I OPERATOR I <br /> PA A j 5'- ll CHECK If BILLING ADDRESS <br /> FACILITY NAME / !!/ <br /> SITE ADDRESS {/// 5 <br /> 3(' Z Street Number Direction ���� r`���Street a e/ r /Cit ZI Code�C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> l `l i <br /> ��' Street Number Street Name <br /> CITYC 7 G i ' `TG -,v CAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT I_OCATjI�)7N CODE <br /> ( ) oc>t_ T <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR (/ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / I S •r� PH NE# EXT. <br /> c-7 CHOME or MAILING ADDRESS FAX# <br /> CITY / 14 STATE ZIP <br /> BILLING ACKNOWLEDGEME T: 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, STgTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: '`?/ � DATE--: Zn <br /> PROPERTY/BUSINESS OWNER❑ /OPERATOR/MANAGER El OTHER OTHER AUTHORIZED AGENT L � ��;(�� ( 6' � <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required Tirrc <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at th above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as``s��_��e��_s��Ls at <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same tlm�1� Q�j�1�le Or <br /> my representative. 1'�� ����Vy <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A <br /> 510-10 <br /> �M Py <br /> �.o,'o <br /> N <br /> ACCEPTED BY: Iliq EMPLOYEE#: DATE: Q,IZZ_ <br /> ASSIGNED TO: EMPLOYEE#: DATE: •a� _ I S( <br /> Date Service Completed (if already completed): SERVICE CODE: JZ PIE: U <br /> Fee Amount: L+15 ILI- <br /> Amount Paid ( 5 LmPayment Date <br /> Payment Type Invoice# Check# qL�- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />