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SAN JOAQuiN COUNTY ENVIRONMENTAL HEAL____ DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ! FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS T f <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7�'� � N�Gnp�c� i4 <br /> Street Number Street Name <br /> CITY u / STATE ,/ ZIP <br /> PHONE#1 EXT. P'PN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR %i j� CHECK If BILLING ADDRESS <br /> G'�ff�/jff� <br /> BUSINESS NAME PHONE# EXT. <br /> z--� 7y-7 7� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY e� J s/ STATE C 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 ENvlRONMENTAL 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:`_r(v�,� -- �-" DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR TY,proof of authorization to 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 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: Rc <br /> Veo <br /> COMMENTS: JA N 0 5 2015 <br /> u Vim- v <br /> Sq Eiv Ute COU <br /> HEAL-r"a y AR MENj r1' <br /> ACCEPTED BY: i U_ EMPLOYEE#: DATE: <br /> ASSIGNED TO: r u o Z_ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pai Payment Date <br /> 3 U 130.007 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />