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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property' FACILITY ID SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK H 91 NG gETDttEgg 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) tf Code <br /> Street N°"` Street Name <br /> CITY <br /> STATE ZIP <br /> PHONE#t ` Ext. APN LAND USE APPLICATION# <br /> r 1 <br /> PHONE#2 *• DOS DISTRICT <br /> ( LOCAT1oN CODE <br /> REQUESTOR CONTRACTOR/SERVICE REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ( <br /> STATE 71P <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> - DATE: <br /> PROPERTY/BUSUass OWNER 13 OPERATOR/MANAGER 13 0T1IERAuTH0R1ZEDAcrnrr❑ <br /> If APPLICAVT is not the BILLING PARTY.proof of authorization to sign is required <br /> 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 environmentaVsite assessment <br /> information to the SAW 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: c��-t-y�F/�t✓E ��/�d-� /����� CG�J�Q-�-{ r iv Y�--'T7 t7,t� ��cl <br /> COMMEWS: <br /> ACCEPTED BY: EMPLOYEE#: <br /> DATE: <br /> ASSIGNED To: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: 3 IS PIE: <br /> Fee Amount: r''p3 <br /> f g p p Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />