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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busi es Property eFAC9-:� Y ID# SERVICE REQUEST# <br /> OWNER TOR �7 x <br /> CHECKi DDRESS El <br /> 1=At:iL �1 O � / C.i J <br /> SITE A ESS�r�k,� � ' <br /> tr .��v r <br />! Street Number Direction Street Name Ci Zi e <br /> E HOME or MAILING ADDRESS (if Different from Site Address) <br /> i <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (,:go 1) 94 F- -73 Ff 1-7-7 -- ©.So —to _ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS[:] <br /> BUSINESS NAME PHONE# EXT. <br /> Y HOME Or MAILING ADDRESS r FAX# <br /> 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared ' a is 'on and that the wor o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ds T E nd FED Iaws <br /> APPLICANT'S SIGNATURE: �/L DATE: �J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 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: EMPLOYEE#: <br /> ASSIGNED 70: 1 ' t V l� 11 EMPLOYEE#: (J �+ 2 DATE: `Y <br /> Date Service Completed (if already completed): �T SERVICE CODE: 1P, <br /> �7 <br /> nt: �• Amount Paid �1 ��j�, Payment Date .�24(0 L, LJ <br /> Pa }/ Invoice# C heck# Recei : <br /> EHD 48-02-025 R ORM(Golden'Rod)' ' <br /> REVISED 11/17/2003 <br />