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SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu ' ess or operty FACILITY ID# SERVICE REQUEST# <br /> 406, <br /> OWNER/ OPERATOR <br /> n � CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS > <br /> Street Number Direction Street ame Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PFIONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME / PHONE# /J � ., <br /> EXT. <br /> HOME Or MAILING ADDRESS �j FAx# <br /> CITY f' r7 ~STATE ZIP <br /> BILLING ACKNOWLEDGE ENT: 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: <br /> /f?, ;' l tjo DATE: ?Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT-0 C 1 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title L <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: t L ENI <br /> COMMENTS: <br /> AUG 2 2 200 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: U` Amount Paid oC� � OL Paymen Date IS I <br /> LZ Ur <br /> Payment Type Invoice# Check# L Received By: C-�-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />