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6 <br />FACILITY ID # <br />Facility Name <br />Site Address <br />City Zip Code <br />Street Number <br />City State <br />Ext.APN#Land Use Application # <br />Ext.BOS District Location Code <br />Ext. <br />) <br />City <br />7 // 4^ p(M <br />-Nt <br />Accepted By:Employee#:Date: <br />Assigned to:Employee#:Date: <br />Service Code: <br />Fee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />07/17/08 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Direction <br />Home or Mailing Address (if Different from site Address) <br />Type of Service Requested: <br />Comments: <br />Street Name <br />Zip <br />Phone it2 <br />() <br />■5 <br />Payment Date <br />c o <br />Vtlv /. <br />Date Service Completed (if already completed): <br />Payment Type . <br />—.A SERVICE REQUEST # <br />Phone #1 <br />( ) <br />Check if Billing Address D <br />Check if Billing Address D <br />2-- (T, - f 7 <br />PIE: <br />Received By: xZ/q/ <br />APPLICANT’S SIGNATURE: " DATE: Zp/f0) <br />Property / Business Owner Operator / Manager Other Authorized Agent EL ______________ <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 infojwoation <br />to the San Joaquin County Environmental Health Department as soon as it is available and at the same time it is provided . <br />my representative. <br />?0l9 <br />Type of Business or Property <br />A'pskfA- m ca iplcy <br />Owner / Operator a <br />S1 <br />Street Name <br />Amount Paid <br /> Check# ^^77 <br />(OD1 Street Number <br />____________________CONTRACTOR / SERVICE REQUESTOR <br />R,°U“T"KU( <br />Business Name .A. ~ TA | T") \ <br />Hqme or Mailing Address <br />r o. <br />U<? C GrcU <br />Phone# , <br />Fax# <br />1 <br />_______________________________________state^ A ZlP [ <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 EefiERAi/laws^ <br />qjaiation