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SAN JOAQUIN -OUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ls�-W6 ��- s�z bus wee <br /> OWNER/OPERATOR • <br /> �\ \ �\�1 CHECK if BILLING ADDRESS <br /> FACILITY NAME �J` `/` ` VL l� <br /> SITE ADDRESS C �\\ <br /> Street Number I io \ treat Name I "\Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> St Street Name <br /> CITY �i(� STATE ZIP <br /> PHONE#'I b v �i 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# ExT' <br /> S ` S 2 U <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ��/ Y(�,^ STATE r,� 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 /> �j�COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. cy <br /> J�/�►PPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER" OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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. P <br /> 117 <br /> TYPE OF SERVICE REQUESTED: cpl <br /> COMMENTS: JA <br /> N <br /> SAJ J0AQ//1 9 2�?Q <br /> y��Ty o pg"'r Jnr <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: '�\�ZGi V-0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid \�ZJ �s ,it Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />