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SANJOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> OWNER OPERATOR <br /> 7 <br /> 'n+, IQ CHECK if BILLING WDRESSJU <br /> FACILNY NAME 1 I <br /> SITE ADDRESS <br /> Street Number Direction Street Name (� Ci Zi Code% <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> () �U 'Z Street Number Street Name 2 <br /> CITYr� C11) $TATE ZIP SZl l <br /> PHONE#1 \�I•'1 / Ext. APN#7 p LAND USE APPLICATION# —Q///---��r <br /> Lo <br /> 7� 2c1G' C ✓7C��i cC'/ <br /> PHONE#2 ''II EiT. BOS DIST LOCATION CODE <br /> c( `I C 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> Eom <br /> R I� l n <br /> `f R CHECK if BILLING ADDRESS <br /> AME PHONE# EIT- <br /> LIN DRE$ FAX# <br /> �\ i.\ STATE ZIP Z I <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,Standard ,\ and FbD L laws. r7 <br /> APPLICANT'S SIGNATURE: •�O-WA tom„/� (� DATE: S ' <br /> PROPERTY/BUSINESS OWNE] PERATOR/MANAGE OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RE <br /> CE(�/ED <br /> SA EN �R NIP N W <br /> ACCE D BY: EMPLOYEE#: DATE: <br /> OL <br /> ASSIGNED TO: EMPLOYEE#: 375' DATE: `'77 <br /> Date Service Completed (if already completed): SERVICECODE:31---57 PIE: <br /> Fee Amount: / Amount Paid �l Payment Date <br /> Payment Type Invoice# Check# ( �-. L; "L, Received By: �j,1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />