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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE 5� REQUE T# <br /> -�0U5 �-7 <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction v Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> PHONE#2EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME EXT <br /> �# <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP 5A <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <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: <br /> COMMENTS: B 0 <br /> SAN O <br /> HEACO <br /> ENVI o tv 8V LTH fPgR M� <br /> ACCEPTED BY: EMPLOYEE#: L DATE: 2 Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: y 2— <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 1 <br /> Fee Amount: Ov Amount Paid 1 Payment Date <br /> Payment Type Invoice# Check# � OLA <br /> Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />