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SAN JOAQUIN COUNTY ENY'IRONNIENTAL HEALT- DEPARTMENT <br /> SERVICE REQUEST <br /> Type of iness or r)�_ertyL FACILITY ID# SERVICE REQUEST[# <br /> ���� � • OOS3�� l - <br /> OWNERPOPERATO <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME / <br /> SITE ADDRESS dedeStreet Number Direction i Zi Cod7e <br /> HOME or MAILING ADDRE (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT APN# LAND USE APPLICATION# <br /> :33(1 Joe. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Z':Z&77t� /j / -Y /t �, CHECK if BILLING ADDRESS <br /> BUSINESS NA (�� �/ / PHONE# Ems' <br /> r i xr /=n _ r <br /> HOME or MAILING ADDRESS � FAX# <br /> CITY ?, / STATE ZIPJ 11�— <br /> BILLING ACKNOWLEDGEMENT: 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 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 a ' lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / / /L DATE: p , <br /> PROPERTY/BUSINESS OWNER 1:1 OPERATOR/MANAGE11 AUTHORIZED AGENT 1 � K <br /> /f APPLICANT is not the BILLING PARTY,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 environ-mental/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. Ell <br /> TYPE OF SERVICE REQUESTED: F�ECE <br /> COMMENTS: <br /> I GOVPIN <br /> SPA <br /> H�LSN CPPB <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: U EMPLOYEE#: ✓Zvw DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 2-4 <br /> Fee Amount: °d Amount Paid ` (� Payment Date a( O <br /> Payment Type ✓ Invoice# Check# ! Received By: L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />