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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Prope FACILITY IDVICE SERVICE REQUEST# A O Q O O iC: OWNER/O BATOR CHECK If SiLUNG ADDRESSO FAauTy NAME SITE ADDRESS Street Number I Di etion HOME or MAILING ADDLE (H Different from a Address) i trael Nama CITY Y ZIP PHONE#1 _ ExT. APN o LAND USE APPLICATION# 1 ) PHONE#2 E". BOS DISTMCT LocnnoN CODE 1 ) CONTRACTOR/SERVICE REQUESTOR REQUESTO I CHECK I BIWNG ADDRESS BUSINESS NAME HOME Or MAIIJNG REe F _ 141 D _ l7� CITY ` STgTE 2-k BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standar , ATE an EDERAL I APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0r1FRAOTHORIZEDAG IfAPPL1cANT is not the B/tuNG PARTY proof if aathorizarion to sign is required Tette AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t)1QWe time it is provided to me or my representative. s_!GD TYPE OF SERVICE REQUESTED: Sl (41 COMMENTS: pE� SA ENS QUIN RONMENTAL. HEALTN OEPAFM04T ACCEPTED BY: _ EMPLOYEEM /l DATE: ASSIGNED TO: EMPLOYEE#: r DATE: A Date Service Completed (H already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 4&02-025 REVISED 11/17/2003 SR FORM(Golden Rod)