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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEREQUEST# <br /> lJ (Pr-zs-7- y I'', <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME J 7 _ i <br /> d✓i� /G/ Di <br /> SITE ADDRESS <br /> t� Street Number Direction / Street Name /� Zi Code <br /> HOME of FAILING ADDRESS (If Different from Site Address) <br /> L(/ fL Street Number Street Name <br /> CITY OSTATE �ZIP�� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION J#S <br /> (u1`-2 ) 1m � a ? q/ <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> COUNTY Ordinance Codes,Standa ST E nd FEDERAL laws. +� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/INfANAGER ❑ 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 t0 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: Ne-LAJ C,v ( �'N►EN <br /> COMMENTS: I1/Ep <br /> MAR U 1 1020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRHEALTH Dip TAL <br /> TMENT- <br /> ACCEPTED BY: S ` EMPLOYEE#: DATE: Z , _ <br /> ASSIGNED TO: S EMPLOYEE#: DATE: 2 -� _ z)—e) <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: S Z �— Amount Paid Payment Date 2 221 <br /> Payment Type Invoice# Check# /l Received By: <br /> EHD 48-02-025 ��� � C/ SR FORM(Golden Rod) <br /> VkREVISED 11/17/2003 <br /> -- 04� d-(.151 <br />