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SAN JOAQL COVNTY ENVIRONMENTAL HEALTi,.,�EPARTMENT <br /> SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR q qhs — <br /> D 10 `� yn P1 0117„J/}� / ` CHECK If BILLING ADORE55 <br /> FACILn'YNAME �JuP L ii " ! 1 L=C_ J ' <br /> }} CC G n � <br /> SITE ADDRESS <br /> 5reet Number irection `-^"`ro Stree N me "�' 1 1 le7 Zde <br /> HO'ME or MAILING MAILING ADDRESS {If Different from Site A dre^s I) <br /> :XBr/ t: l� �' V Street Number Street Name <br /> CITY STATE Z]P <br /> Pi10NE#1 EXT APN# LAND USE APPLICATION# <br /> 6 � rZ <br /> HONE#2 `` / Err. BO$DISTRICT LOCATION CODE <br /> 6 <br /> { O O <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> i <br /> BUSINESS NAME PHONE# EXT. / <br /> HOME or MAILING ADDRESS FAX# <br /> f 1 <br /> CITY 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 <br /> or 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 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERAT I ANAG OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof Of authorization t0 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 COUN'T'Y ENVIRONMmNTAL HEALTH DEPARTMENT as soon as it is available and at theme time it is <br /> provided to me or my representative. 4)e <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �- sqN J 19?D13 <br /> --Gz-J"G HE��H gDMF coU <br /> DEF,q Ir <br /> TMENT <br /> _ � f <br /> ACCEPTED BY:. / EMPLOYEE : DATE: <br /> s Pl <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��� P!E: Z <br /> Fee Amount: �— Amount Paidlent Date <br /> Payment Type6W— Invoice# Check# Received By:7✓ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> • - s <br />