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SAN JOAQUIN COUNTY ENVIRONN WNTAL HEALTH DEPARTMENT <br /> .1; <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS� <br /> FACILI AME <br /> SITE ADDRESS <br /> �/j <br /> i 3 Street Number I Direction •rte V - Street Name lIUJJ Cit _Lm Code <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE M ExT. APN# <br /> PIBOS LANDUAP-ICAOTION# <br /> RICT <br /> PHONE#Z ExT. IST <br /> LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ��/ / CHECK if BILLING ADORE <br /> �L /) . <br /> ;�Z 7/ .. PHONE# Exr. <br /> BUSINESS NAw �O, Q <br /> Q <br /> HOME or MAILINGDDRESS FAX# <br /> ST <br /> ( ) <br /> STATE ZIP <br /> CITY <br /> BILLING ACKNOWLEDGE ENT: 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. <br /> APPLICANT'S SIGNATURE: ✓� DATE: �D <br /> PROPERTY I BUSINESS OWNERtr OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tine <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: ECEIVED <br /> I _ e Q <br /> COMMENTS: 3�1 I - //08 <br /> C4]I IO�/ JUL E� ZOOU <br /> 64 <br />} M-E �SCc'T7r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> t <br /> HEALTH DEPAIRTMENT <br /> ACCEPTED BY: EMPLOYEE#: IMP DATE: <br /> ASSIGNED TO: EMPLOYEE#: DAT-SIE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P f E+ <br /> Fee Amount: d Amount Paid � 'lo , Payment Date i 6 C <br /> Payment Type n,� <br /> Invoice# Check# � S Received By: <br /> EHD 48-02-025 ,SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />