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0ruv a u W Uuv %-V UN i Y it N V IRUNMEN I'AL LiEALTH DEPARTMENT <br /> --J - SERVICE REQUEST <br /> Type of Busi ess or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/O E TOR f Il <br /> - - -- 1 CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 <br /> $READDRESS (/D'—I <br /> 5"tfreel merirection 6l et Name A / (5J Zt ode <br /> HOME or MAILING ADDRESS af Different from it Address <br /> Street Number Street Name <br /> CIN lul, STATE ZIP <br /> PHONE#I Ea . APN# LAND USE APPLICATION# <br /> ('0107) <br /> PHONE#2 EKr• BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR e <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME llllll��� PHONE EXr• <br /> / 1^ <br /> HOME Or MAILING ADD S 0 FAX# ' <br /> 1 ) <br /> CITYAK M, STATE zip <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , TATE and FEDRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: // � fa <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENT <br /> -IrAPPLICANT is not the BILLINGPARTY proof of authorization to sign is required Titre <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: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 O♦ ( old0, -ROO)� <br /> REVISED 11/17/2003 <br />