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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5< cel ZL4 5 <br /> OWNER/ PIELRATOR <br /> CHECK if BILLING ADDRESS <br /> 111-7 <br /> FACILITY NAME G <br /> Su ADDRESS//�[// <br /> �"" z— ' " St eet Number Direction � treet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STg.TC� ZIPS-�� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> —7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHO E# EXT' <br /> mor MAILING ADDRESS FAX# <br /> !2p D (cqe-v <br /> CITY �r-7� � STAT ZIP 9 SZ <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 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, A' and FEDERAL law <br /> APPLICANT'S SIGNATURE: DATE:�z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /yam <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tit e <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: <br /> 8 9 <br /> h�CM'l�p�wCO <br /> ACCEPTED BY: EMPLOYEE#: DATE: /1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: �J <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E. <br /> Fee Amount: Amount Pai S� Payment Date �� S <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />