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SAN JOAO COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -T-R <br /> OWNED/OPERATOR/� <br /> �C G� L/ t y CHECK If BILLING ADDRESS O <br /> FACILITY NAE <br /> /' (A k61 <br /> SITE ADDRESS <br /> s ^t^ r ' S <br /> Street Number Direction �W ( treet Name Zi de� <br /> HOME or MAILING ADDR Sf Different from Site Address) <br /> Street Number Street Na� <br /> CITY STATE ZIP <br /> PHONE#I 3/EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1/' / u /Jere CHECK If BILLING ADDRESS <br /> BUSINESS NAME v11' C PHONE# EXT. <br /> lr <br /> HOME or MAILING ADDRESS // FAX# <br /> T ) <br /> CITY1 / [ A� STATE ZIP j <br /> 206 <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 SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNERERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ifAPPL/CANT 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 sat Ime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ) r ��• �� <br /> COMMENTS: C <br /> 1 <br /> ( <br /> 1 ` �; y Fi►n,R Q411 2�fy <br /> �� V 024/v cou,, <br /> C�� <br /> �RTMFNT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: vac EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P1 I Q� <br /> Fee Amount: Ll CIO 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 />