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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> y7• .s <br /> SERVICE REQUEST ` <br /> Type of Business or Property FACILITY ID# SERVICE'REQUEST# <br /> OWNER i OPERATOR <br /> CHECK ifBILLING ADDRESS[ <br /> BXILU -A- <br /> FACILlTYNAME <br /> SITE ADDRESS 1`2 ©�� �• ���, ���.� <br /> Street Number.—Direction Street Name Ci ' 'U'n: Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 E(T• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR11/1 <br /> ,. CNECK if E3ILLING ADDRESS'v' <br /> BUSINESS NAMErp�� PHONE# EXT.y Cx 4 <br /> ul. �S (q[� <br /> HOME Or MAILING AnDRESFAX#&,,,, <br /> CITY STATE n tq ZIP( <br /> BILLING ACKNOWLEDGEMEN11: 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 identifie n this form. <br /> I also certify that I have prepared this application ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE it la s. <br /> APPLICANT'S SIGNAT DATE: ,'t2-C,'0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENT Q.,�14(,l x.(ipj <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: ` 'NT <br /> COMMENTS: REC �V EU <br /> APR 2 9 cUu8 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z. <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: jW <br /> P l EZb b/ <br /> Fee Amount: '8 ! �� d Amount Paid -� f D Payme t Date <br /> Payment Type ✓ invoice# Check# 5vZ— Received By: <br /> EHD 48-02-025 �S FQRNI(olden_ odj'' <br /> REVISE=D 11/17/2003 <br />