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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> .r Business or Property FACILITY ID# SERVICE REQUEST# <br /> JWNER 1 OPERATOR CHECK if BELLING ADDRESS❑ <br /> 1 <br /> r <br /> FACILITY NAME <br /> WAT <br /> r <br /> SITE ADDRESS --2 �' � ^( sZ`j <br /> Street Number Direction Street Name City <br /> Zi Cade <br /> HOME or WAILING ADDRESS (If Different from Site Address) <br /> c C- o C Street Number Street Name <br /> CITY _$TAT5 ZIP <br /> T` '✓ <br /> PHONE#iExT. APN# LAND USE APPLICATION# <br /> 2 <br /> / Q l <br /> PHONE12 EXT. 80S DISTRICT LOCATION CODE <br /> ^ 2 <br /> CONTRACTOR 1 SERVICE REQUESTOR t11 <br /> N <br /> REQUESTORp <br /> CHECK if BILLING ADDRESS❑ lV <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> ) <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 this application and that the work to be performed will be done in accordance wid Awmab%UIN <br /> COUNTY Ordinance C tan a TE and FEDERAL laws. RECEIVE'"' <br /> APPLICANT'S SIG ETRE: r DATE: <br /> PROPERTY/BusiNESs OWNER❑ OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT❑ �`(. <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required v1Ppi 1MgEl,4TAL f <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the proV€ %Val ed at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> 1 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 /> t TYPE OF SERVICE REQUESTED: UQ <br /> COMMENTS: - o tze� VV <br /> ACCEPTED BY: EMPLOYEE#: 3DATE: <br /> ASSIGNED TO: EMPLOYEE#: O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: j7/ <br /> Fee Amount: u' Amount Paid - ['7 fl Payment Date <br /> Payment Type lnvnice# Check# Received BY: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> r' <br />