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SAN JOAQUIN COL ENVIRONMENTAL HEALTH DEPARTMENT <br /> aERVICE REQUEST <br /> Type of Business or Property FACILITY I D# SERVICE RECL EST# <br /> OWNER/OPERATOR CHECK if BILLING ADD RESS❑ <br /> FACILrTY NAME <br /> SIIEAD>FiE.ss <br /> Streel Number I Direction Street Name city Zip Code <br /> HwEor MwurcAmREss (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHME#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE t12 EXT. BO DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> R EQ UESTO R <br /> CtsEGc If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 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,Standards,STATE and FEDERAL IaWS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the B2uroG 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 above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or <br /> my representative. <br /> TrnEoF SSzaICEREQLESTECX <br /> Co AtENrs: <br /> ACCEPTED BY: EMPLOYEE#i DATE: <br /> ASSIGNED TO: EMPLOYEE Ik EhTE: <br /> Date Service Completed (if already completed): i—cEOODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48 02-025 SR FORMden Rod) <br /> 0//17108 CEI VEp <br /> AUG p 4 ?ii„} <br /> ftlRONMENT, L HEi4T8 <br /> PERMIT/sEwce <br />