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SAN JOAQUIN COUNTY ENVIRONTNIENTAL HEALTH DEPART <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# \ <br /> OWNER/OPERATORCHECX If BILLING ADDRESS <br /> AGILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction W Street Name C ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) � <br /> Street Number {V\ Street Name <br /> CITY (` ST,&TE, ZIP �1 �J <br /> PHONE#1 EXT• APN LAND USE APPLICATION# <br /> ( moi) Lf 06 - (a Z-4 - I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION DE <br /> ( ) C) I� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �1n� �^�\ CHECK IT BILLING ADDRESS <br /> BUSINESS NAME v `'1 l J PHONE# EXT. <br /> HOME Or MAILING ADDRESS � � \ (Ax#Sao <br /> ) � �ijf�r.• � <br /> CITY m5tN� STATE /!► 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 ENVIRONNfENTAL 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 wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAT aws <br /> APPLICANT'S SIGNATUR4� DATE: r _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLNG 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 s**aRRm it is <br /> provided to me or my representative. "'1( <br /> 0r-r% <br /> TYPE OF SERVICE REQUESTED: ` �, ,, l ��c 1 <br /> COMMENTS: <br /> W6 LU I <br /> V V <br /> SAN AOM RUIVA ON1 N <br /> H,�pLTN 0 <br /> ACCEPTED BY: EMPLOYEE#: DATE: G <br /> ASSIGNED TO: 'V`4A U--r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PIE: <br /> Fee Amount: q JAmount Paid3G b Payment Date g 1� <br /> Payment Type Invoice# Check# (,�kS`l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />