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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 /> r VIO I -� OfOl� 09"Q fl '2' CHECK if BILLING ADDRESS <br /> FACILITY NAME � I v <br /> SITE ADDRESS <br /> St <br /> HOME or MAILING ADDRESS (If Diff rent from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- 7)k <br /> N# LAND USE APPLICATION# <br /> (Z pk q� `-PZ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ere /4q <br /> HOME or MAILING ADDRESS FAX# <br /> CITYdl d` / STATE zip �o/t7 r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorizedagentof 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,STATE and FEDERAL laws. /� q <br /> APPLICANT'S SIGNATURE: DATE: <br /> � T `V G <br /> PROPERTY/BUSINESS OWNER❑ OP ATOR/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, 1, 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. PA <br /> TYPE OF SERVICE REQUESTED: <br /> VILL— <br /> COMMENTS: �&J <br /> O <br /> H�FHR ?� <br /> JO MEOUN0TyON <br /> �ePgRMNT <br /> Aj <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ \� e� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I Eg90 Z_ <br /> Fee Amount: \ _ (� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />