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V <br /> 1/9 JOAQ_ _ COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> AUGv� <br /> D SERVICE REQUEST <br /> iI iF/�F ness or operty FACILITY 0# SERVICE REQUEST# <br /> OWNER/OPERA <br /> CHECK if BILLING ADDRESM <br /> FACILITY NAME254 <br /> C <br /> SITE ADDRESS <br /> Street N�mber Direction Street Name i Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) "v�l�� <br /> --JCA Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. <br /> x Q 33-'1 b 1 b BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 <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,ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 <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. <br /> TYPE OF SERVICE REQUESTED: T C t U/ L <br /> COMMENTS: <br /> L >:�Zl- /-�-- <br /> pjG 0 7 2006 <br /> SAN JOAQUIN COUNTY <br /> VIRONMENTAL <br /> Krr <br /> ACCEPTED BY: EMPLOYEE#: DppLTH D <br /> ASSIGNED TO: EMPLOYEE#: tvFxDATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �fi <br /> Fee Amount: r Amount Paid 1 S , 5b Payment Date Sp f6� <br /> Payment Type Invoice# Check# S Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />