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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHI)ErArcr<uae-i. <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> • S(Z©o 5 18 4 <br /> OWN PERAT R CHECK If BILLINGAADDRESS <br /> AME <br /> SITE ADDRESS / 7 �' <br /> (� Street Name Ci 2I ode <br /> Street Number Direction <br /> HOME or M�NCz AgDRES (If Different fr Site ddres r <br /> bi Street Number Street Name <br /> SrQIe <br /> CITY ZIP <br /> �� <br /> PHONE#1 <br /> EXT. APN# LAND US PLICATION# _^T _ <br /> -f/J✓ <br /> R,f ) 7 ©7c� l�FD- <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> 4 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> PHONE# <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAT(# <br /> l ) <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 with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST,gg andDERAs. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ AGER 11 OTHER AUTHORIZED AGENT 1:1 <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and att4e same time it is <br /> provided to me or my representative. rr A 1" -- <br /> TYPE OF SERVICE REQUESTED: C,& Co NT� / <br /> COMMENTS: SAN 6 200, <br /> ACCEPTED BY: EMPLOYEE#: ? DATE: 9 0� <br /> ASSIGNED TO: EMPLOYEE#: 15tY[rG DATE: r,(07 <br /> Date Service Completed (if already completed): SERVICE CODE: -3/5 PIE D3 <br /> Fee Amount: l g Amount Paidl �, — Payment Date k(. Q 7 <br /> Payment Type ✓ Invoice# Check# i cis Receivedf By: , <br /> EHO 48-02-025 " ti F '(Golden Rod) <br /> REVISED 11/17/2003 <br />