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SAN JOAQUIN�UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST i <br /> Ty f Business or mt�) <br /> FACILITY ID# SERVICE REQUEST# <br /> c ' 0 <br /> OWN01 OPERATO <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME - � <br /> SITE ADD ESS <br /> Street Number direction <br /> HOME or MAILING ArESSS (if Different from Site Address) <br /> 1 r Street Number Street Name <br /> CITY STATE ZIP Ay Jy\ <br /> PHONEA ET. APN# LAND USE APPLICATION# <br /> �><r. BCS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR L tn V1 <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME n PHON / <br /> i <br /> HOME or MAILING ADDRESS / i FAX# ) ,t ,^ <br /> CITY / STATE <br /> BILLING ACKNOWLED EMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONmtEN rAL 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 applica o and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE an FEDrygnl la <br /> APPLICANT'S SIGNATURE: ( � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENTI� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titte <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 environmentaysite 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: / S A RECEIVED <br /> COMMENTS: 0 3 ,50 1706 JUL 2 S 2005 <br /> ��� 3 r z "► ? !/`'' SAN JOAQUIN COUNTY <br /> 1 HEALTH DEPARTTMENT <br /> ACCEPTED BY: EMPLOYEE#: C DATE: 7 d-� <br /> ASSIGNED TO: CJC)�1 EMPLOYEE#: DATE: C/ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 2-309 <br /> Fee Amount: 7 ZAmount Paid n Payment Date <br /> Payment Type Invoice# Check# l ']� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) ` <br /> REVISED 11/17/2003 <br />