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SAN 3OAQUUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property ��� <br /> OWNER/OPERA OR O (�_ CHECK If BILLING ADDRESS <br /> FACILITY NAME le <br /> SITE ADDRESS <br /> ESSpy �` (� `"ti, <br /> Street Number Direction <br /> eet Name cuity <br /> i ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE zip <br /> CITY <br /> EXT- qPN#) LAND USE APPLICATION# <br /> PHONE#1 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR -- CHECK ifBILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME y�0 I" � <br /> HOME Or MAILING ADDRESS �J �� FAX# <br /> STATECA zip (�'�K'— <br /> C 1 <br /> CITY v <br /> r <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: tty. �� DATE: <br /> PROPERTY 1 BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of alrtlrorization to sign is required Tale <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 environmentallsite 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. 4 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> NN;`( <br /> SP JCP o ME A NA <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE! <br /> Date Service Completed (if already completed): <br /> SERVICEr. -nt <br /> Fee Amount: / � OV LO Amount Paid } Date <br /> Payment Type V Invoice# Check# S Received <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />