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Y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> I y a <br /> FACILITY ID# SERVICE REQUEST# <br /> Tof B sines or Propert <br /> MA-20 11 3z <br /> OWNER 10 RATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS } LLW��fiii . <br /> Gtreet Number Direction AA tree am <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br />'I rn, Street Number tr t Na <br /> STATE ZIP <br /> CITY <br /> PHONE#f ExT APN# LAND Use APPLICATION# <br /> 001) 15,961� 5 <br /> P NE#Z EXT. BIDS DISTRICT LOCATION CODE <br /> L( <br /> f CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESSD <br /> ` 1 4 PHONE ExT. <br /> BUSINESS NAME <br /> # HOME or MAILING ADDRESS FAX# <br /> k ( ) <br /> E 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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE an ERA\laws. <br /> APPLICANT'S SIGNATUR DATE. <br /> BROPER'rY I BUSINESS OWNER© OPERA MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPZICAATT is not the BigiNG 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 /> COMMENTS: <br /> ACCEPTED BY: e EMPLOYEE M DATE: I,0`k 2 �� <br /> ASSIGNED TO: EMPLOYEE#: DATE: t _— <br /> 4 `Q <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: t .0 <br /> Fee Amount: Amount Paid ' Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 `4 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />