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SAN JOAQUI'- `".OUNTY ENVIRONMENTAL HEALT -)EPARTMENT <br /> SERVICE REQUEST <br /> =ss or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Directio Street Name 4ity 2i Code <br /> HOME or MAILING ADDRESS (If ifferent from Site Address) <br /> Street Number Street Name <br /> ATE ZIP <br /> i <br /> PP4E# EXT. APN# LAND USE APPLICATION# <br /> (°)25) L\q3-Cly <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# � EXT. <br /> -Act'6 <br /> HOME or MAILING ADDRESS FAX# <br /> Z© �! ( ) <br /> CITv S TE ZIP <br /> BILLING AC OWLEDGEMENT: 1, 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 and FEDERAL laws. / ) <br /> APPLICANT'S SIGNATURE: DATE: /GY <br /> PROPERTY/BUS[NESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 31 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I`S ✓I'1 EMPLOYEE#: DATE: 4 3` S <br /> Date Service Completed (if already completed): SERVICE CODE: e- 4f)&( P I E: (�,cFL <br /> Fee Amount: (30 r CIO I <br /> Amount Paid 13 C9 Payment Date 2 3 r ( 5— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />