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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> OWNER/ ERAT R <br /> � � I C' CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> rLl� 5�-3 <br /> d Street Number Direction Street Name O �Zi Cade 7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 05/- 3ZO- /0 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �Om j / <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME/ C� J O PHONE <br /> HOME or MAILING AD v (Ax# <br /> Ci DRESS <br /> —�/ <br /> CITY / C��i 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 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. q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ Oy ORATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is requirCa 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 t0 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: ,qT <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> SEP 25 20 <br /> IAN JOAQUIN COUNT' <br /> EtMRONMERTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: G' <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 2s PfE: 3 <br /> Fee Amount: Amount Paid N Payment Date Z J <br /> Payment Type G Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />