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e — . <br /> SAN JOAQU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �QIJEST#7 <br /> OwNE RAT <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS OZ( (4 0 IN <br /> Street Number Diracdon Street Name i Cotle I <br /> HOME or MAILING ADDRESS (If Differe from Site Address) <br /> Street Number Street Nama <br /> Cl <br /> TATE p <br /> PHONE at Ext APN# LAND USE APPLICATION# <br /> PHONE#2 aT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK H BILLING ADDRESS 0 <br /> BUSINESS NAME <br /> PHONE# <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY ( ) <br /> STATE LP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this applicati0pand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, d F E a <br /> APPLICANT'S SIGNATURE: DATE' �� �tq�_ <br /> ❑ <br /> PROPERTY/BUSINPSs OWNEROPERATOR/MAN GER OTHER AUTHORIZED AGENT 13 <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: e2, a cu /4-CE OA1 -^4 t� �U.� <br /> COMMENTS: to-4 <br /> _K] lL/12 P/''YMIVEO <br /> !�c�crtTlTx+Ji�j ,�D RE <br /> ZU5 <br /> ACCEPTED BY: OUIN GOUNN <br /> O L-(t,/&,W—4 EMPLOYEE#: �3 2-4 DA �¢N tF p1ENT <br /> ASSIGNED 70: S C G' EMPLOYEE#: S'I Lt Lf DATE: 3 /IC 1 <br /> CIS <br /> Date Service Completed (If already completed): SERVICE CODE: 5 (S PIE: G �, g <br /> Fee Amount:- ( g(�.L'�� Amount Pald <br /> Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/172003 SR FORM(Golden Rod) <br />