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JANJOAQUINCOUNTYENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sK oc4aol <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS Ll <br /> FACILrrY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name L C' Zi Code <br /> HOME Or MAILING ADDRESS (If Differen from Site Ad less) rrI{{I <br /> —/O Street Number ieetName CITY STAT <br /> PHONE#1T' APN# USE APPLICATION# <br /> ( 119) 23Li - 11611 1C 12 <br /> PHONE#2 T BOS DISTRICT LOCAsCODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Es'' <br /> HOME or MAILING I ESS FAx# <br /> f ) <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 A Identified on this form. <br /> I also certify that I have prepared this app ' n and t the wor be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S nd FE laws. <br /> APPLICANT'S SIGNATURE: DATE: 4 <br /> PROPERTY/BUSINESS OWNER❑ OP OR/MANAGER OTHER AU"CHORIZED AGENT❑ <br /> IfAPPL/CAmT is not the B G PARTY proof f a horizalion to sign is required Title <br /> AUTHORIZATION TO RELEASE FORMATION: 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 environmentallsite 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: 1 <br /> COMMENTS: <br /> OCT 2 0 Zoos <br /> ,00%COU01`1 <br /> SAN NV llvwENTAi- <br /> TH DEPARTMENT <br /> ACCEPTED BY: MPLOYEE#: /n DATE: 1 ,4 <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: 52 2_ PIE: b <br /> Fee Amount: Amount Paid _ tayment Date <br /> � P <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 `..SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />