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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 SERVICE REQUEST <br /> 7y f Business Prope7 <br /> FACILITY ID# SERVICE REQUEST# <br /> -0 <br /> OWN�k IOPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number/ Direction Street ame Ci 2i Code <br /> HOME or MAILING A DRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> RHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> !/ (iNEGK If BILLING ADDRESS <br /> BUSINESS NAME _ PHON EXT' <br /> ( 7 <br /> HOME or MAILING A D ESS � Fax# <br /> CITY STATEIP <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 appli ti n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> J DATE: <br /> PROPERTY/BUSINESS OWI`1EIt❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY,,proof of authorization to sign is required Title <br /> AUTHHORIZATION 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 av_a�l 5nd at the same time it is <br /> provided to me or my representative. �,'{yell�- (� <br /> TYPE OF SERVICE REQUESTED: 0� <br /> COMMENTS: �p�( 00 <br /> G'� <br /> JdPQ pIME���� <br /> SP11tNp�pP��M <br /> N <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: 111,Ar r EMPLOYEE#: 3 U DATE: <br /> r <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: v Amount Paid Payme Date <br /> Payment Type Invoice# Check# ��J Received By: I <br /> EHD 45-02-025 SR FOFtM.(Galdeir'Rod) ' <br /> REVISED 11117/2003 <br />