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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9eS(6en&lo.L Load S CIJ�31`�gZ <br /> OWNERI qPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C �J� <br /> Street Number Direction SVeet Name city '1 Zip Code <br /> HOME <br /> �orr MAILING ADDRESS (if Different from Site Address) <br /> — J-L Z� <br /> 1 5 Street Number Street Name <br /> CITY �(`p,nn� ��� ^ c� Q\S 2.,�� $TATE ZIP <br /> PHONE#1 ` ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# w jI <br /> HOME or MAILING ADDRESS FAx �i <br /> CITY STATE ZIP APA✓0 <br /> 41. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize ��e, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wit <br /> or activity will be billed to me or my business as identified on this form. FHT <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 laws. <br /> APPLICANT'S SIGNATURE: V ' w� _ &MQ� DATE: <br /> PROPERTY/BUSINESS OWNEA9 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Pai D O ''�m Payment Date / <br /> Payment Type 1' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />