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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RETEST# <br /> k � s 0 (J I <br /> OWNS 7 <br /> /OPERATOR_ <br /> CxA-\ p CHECK if BILLING ADDRESS <br /> FACILITY NAME L <br /> SITE ADDRESS �nl� � <br /> " � Street Number Direction V' St, e e ��'Ci U ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 (�� <br /> Street Number —` Street Name <br /> —� <br /> CITY �O C�; STATE^ '/t ZIP <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# U <br /> Y-1, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /(% V t CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME(\ PHONE# EXT. <br /> a o1 _s <br /> HOME or MAILING ADDRESS FAx# <br /> Z) <br /> CITYcJ 0�; STATE C ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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, T TE and FEDERAL laws.IN (� <br /> APPLICANT'S SIGNATURE: ` 0 DATE: <br /> Q�J�� I <br /> PROPERTY/13USINESS OWNER❑ I OPERATOR/MANAGER ❑ 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. ft <br /> TYPE OF SERVICE REQUESTED: 1 `� <br /> COMMENTS: <br /> SEP <br /> &%U0 <br /> H NV1R0N' y�O <br /> N�EPgRNTAC <br /> ry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Compl ted (if already completed): SERVICE CODE: P I E' <br /> Fee Amount: a Amount Pai �oy 00 Payment Date <br /> Payment Type Invoice# Check# 'lb7f C>LG32— Received By:YELF <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />