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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SEERVII�C--��E'' REQUEST# <br /> 4G r C-1 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> d � <br /> FACILITY NAME <br /> SITE ADDRESS 1� A �r Oria <br /> ' Street Number Direction Street Name tc/ Cit Vl/ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY r S TE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 l EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � ///��� t r ��� CHECK if BILLING ADDRESS <br /> BUSINESS NAME -J ' PHONE# EXT. <br /> HOME or MAILING ADDRESS ' +-` l� ; Ll n C) FAX# ) <br /> lJ 1�0 V 'L <br /> CITYjf i�.� STATE n ZIP e-A <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: n r DATE: — L <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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: �i U M <br /> COMMENTS: qy F T <br /> �Ci; e <br /> �DEC <br /> 0 4 Z019 <br /> Oq <br /> ACCEPTED BY: EMPLOYEE M DATE: M <br /> ASSIGNED TO: EMPLOYEE M DATE: SWT <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Pai Payme ate q <br /> Payment Type Invoice# Check# Received By/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />