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SAN JOAQUIOUNTY ENVIRONMENTAL HEALTH.r„�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ti CHECK If BILLING ADDRESIS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction T Street Name <br /> HOME or MAILING ADDRESS (if Different/o Site Address) <br /> Street Number Street Name <br /> CITY STATE Zi P. <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT FOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE zip <br /> r. 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,S ATE and EEDERAL laws. <br /> APPLICANT'S SIGNATURE: -7DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTH R AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY_,proof of authorization to sign is require 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 San time It 1S <br /> provided to me or my representative. /Vq <br /> { TYPE OF SERVICE REQUESTED: 6d� �L J '► <br /> COMMENTS: <br /> . 3rd �-� ��`' 26- 1 <br /> y FN g4q 0 <br /> I �T <br /> ACCEPTED BY: EMPLOYEE M qd DATE: �� /s- <br /> ASSIGNED TO: �� �� � EMPLOYEE#: j DATE: 2-6 &S <br /> 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:/(p p f <br /> Fee Amount: DDO Amount Pa' Payment Date �S <br /> Payment Tye Invoice# Check# $�j� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> { REVISED 11/17/2003 <br />