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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T��ICt ry Ci %�dCu S� 0 (2\12\ <br /> OWNER/OPERATOR <br /> �I•�LI � �� J ,����� l� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction t/v /Street Name Cit Zin Code (7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> "" <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2� 7-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> < - CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS l a 4,J FAX# <br /> CITY v'�a / /Vt/1� STATE C ZIP q-Sv l l <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 application and tha work to be performed will be done in accordance ith all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and F L I ws. <br /> l <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11/f APPLIC T 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 environn Ttal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ancftj C y}e time it is <br /> provided to me or my representative. !� <br /> TYPE OF SERVICE REQUESTED: S �'� ,�. <br /> COMMENTS: <br /> ON C <br /> Ty pFP���N� <br /> ACCEPTED BY: ��, �d^�---t-- cl, L EMPLOYEE M DATE: ; < I i� <br /> ASSIGNED TO: \1 T��/ C' EMPLOYEE M DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: P : <br /> Fee Amount: \5'L.QO Amount Paid I�a Payment Date <br /> Payment Type Invoice# Check# G Received By: <br /> EHD 48-02-025 n n \ f ` p SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />