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SAN JOAQUINCOUNTYENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICr, REQUEST <br /> Type of Business or Property FACILITY 1D# "� SERVICE REQUEST# <br />� <br /> OWNER I OPERATOR �. CHECK If BILLING ADDRESS <br /> ITY NAME <br /> SITE ADDRESS � p �J --�� r � � ) � <br /> 1Streeet Number Direction Street Name ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CQ E <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTORLk,FJ , <br /> M <br /> A X � CHECK if BILLING ADDRESS <br /> Loa <br /> BUSINESS NAME � � PHONE# <br /> HOME Or MAILING_ ADDRESS FAX# <br /> `D 0 X, La <br /> CITY coSTATE 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,Stand s,STATE and FE ERAL laws. <br /> APPLICANT'S SIGNA DATE: <br /> PROPERTY/ 3USINFSS OWNER❑ OPERATOR I ANAG R ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIc�iNT is n BILLING PAR r of 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 ,WWREQS. <br /> UESTED: <br /> SAN�pP ��A�t+IC <br /> �NVt�xO�PAp;TNI � �� <br /> A PTSD BY: 1 EMPLOYEE#: <br /> ASSIGNED TO: + EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P!E: <br /> Fee Amount: 07 Amount Paid Payment DateI oh AI <br /> Payment Type C7 G Invoice# Check# A Received By: 4) <br /> EHD 48-02-0251 r <br /> � SR FOf�M(Gold n Rod} <br /> REVISED 11/17/2003 <br />