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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> y CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction SVIO tree,Name /^� � Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 30 0 G 6 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND SE APPLICATION K <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> �. CHECK If BILLING ADDRESS <br /> )�' c' L.< <br /> BUSINESS NAME PHONE# <br /> 2" <br /> HOME or MAILING ADDRESS FAX# <br /> t <br /> r 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 <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, E and FEDER laws. <br /> APPLICANT'S SIGNATURE: 'Iev <br /> DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 6 OTHER AUTHORIZED AGENT❑ .5ceAJ .yo2 <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. <br /> TYPE OF SERVICE REQUESTED:!! <br /> COMMENTS: 401 <br /> L- <br /> ooa 5' 00). F/VF T <br /> hEy� 0 <br /> M,�Ro t�ti� 019 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: l DATE: J <br /> Date Service Completed (if Iready completed): SERVICE CODE: ��` P <br /> Fee Amount: Q Amount Paide Payment Date !� <br /> Payment Type Invoice# Check# UU 9;L-3 I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />