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. a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER(OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME A <br /> SITE ADDRESS <br /> Street Number Direction Street Name -citv Zip Code <br /> HOME or MAILING ADDRESS Ilf Different fro Site Address) <br /> Street Number Street Name <br />` CITY STATE ZIP /}� W <br /> PHONE#1T APN# Z LAND USE APPLICATION# <br /> PHONE#2 T BOIS DISTRICT LOCATION ODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILunG ADDRESS <br /> BUSINESS NAME f ' PHONE# EXT <br /> 121 <br /> t2 f,4_' coq 334 <br /> HOME orMAIUNG ADDRESS 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 <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 that the work to b erformed will be done in accordance with all SAN JOAQUIN„ <br /> COUNTY Ordinance Codes,Standards,STAT d FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY pro0 of authorization to sign is required Time _ <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 i <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: A �^ r <br /> COMMENTS: t / �T PAYMEPiT <br /> (� <br /> RECEIVED" <br /> �n �� <br /> G OCT 2 1.2'610. <br /> n SAN JOAQUIN=Wry <br /> ACCEPTED BY: EMPLOYEE#: , rte DATV�AITHD PARTtn i D <br /> ASSIGNED TO: S EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE:O"D <br /> Fee Amount: Amount Paid `'' Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM!(Golden Rod). <br /> REVISED 1111712003 <br />