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SAN JOAQUOFOUNTY ENVIRONMENTAL HEALEPARTMENT <br /> Type of Business or Property SERVICE REQUEST <br /> op <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> sin <br /> FACILITY NAME !.p_ CHECK if BILLING ADDRESS 0 <br /> SITE ADDRESS <br /> Street Number Direction ���� G•t�' s3 <br /> Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> C' ZI Code <br /> CITY Street Number <br /> Street Name <br /> C-A— STATE ZIP <br /> PHONE#t Ecr. 9s3 � <br /> la <br /> APN# <br /> e�) LAND USE APPLICATION#g3z ��3 <br /> PHONE#2 Ex <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME — - <br /> �} LO PHONE# Exr. <br /> HOME or MAILING ADDRESS <br /> Fax# <br /> CITY �^1 ( ) <br /> v* ' STATE ZIP 933-+4L <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 2 "C' &- <br /> DATE: 1 <br /> PROPERTY/BUSINESS OWNER <br /> ❑ OPERATOR/MANAGER ❑ <br /> 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 <br /> provided to me or my representative. 15 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � ) <br /> "Jut <br /> SAENvQlRAaN)N COUNTY <br /> MEALTN D N EN <br /> �ACCEPTED BY: EMPLOYEE#: ^^^TTT i DATE: a, <br /> ASSIGNED 70: EMPLOYEE#: � '7 <br /> 11 DATE: <br /> Date Service Complete (if already mpleted): <br /> SERVICE CODE: PIE: Z 3 U <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />