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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FP#'iLITY ID# SERVICE REQUEST# <br /> ��CIC;�C CSC <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM ` <br /> ,\. _ _ <br /> SITE ADDRESS *') �( �C��` E 1 CN eln ( �(. J ), < (- <br /> ` 1 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP _ <br /> H ( - <br /> PHONE#'1 EXT- APN# LAND USE APPLICATION# <br /> t�6- J�_F -tT5-6 <br /> PHO N #TEXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> t ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator olas <br /> uthorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chargesociated 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 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-- DATE: c - <br /> PROPERTY/BUSINES$I WNEIK OPE TOR/MANAGER ❑ OTHER UT11ORIZED AGENT El--V–APPLICANT is not the BILLING PARTY,proof of autho�iz Pon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFOIZAIATION: 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. 'q Y <br /> TYPE OF SERVICE REQUESTED: ��W7 <br /> COMMENTS: <br /> T 1 <br /> SAN.I p 200 J <br /> H EN�iq qU/N <br /> EA�TjyOFpgR��N�Y <br /> T <br /> ACCEPTED BY: 0 L t � �I L2 EMPLOYEE M � � � DATE: a 1 <br /> ASSIGNED TO: - EMPLOYEE#: Gt C DATE: i <br /> Date Service Comp eted (if already completed): SERVICE CODE: �� P I E: 1661 <br /> Fee Amount: Amount Paid ac�}� oo Payment Date g <br /> Payment Type Invoice# Check# ,/` Received By: <br /> EHD 48-02-025 SIR FORM'(. en Rod) <br /> REVISED 11/17/2003 <br />