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SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTF T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Pqsiness or Property,, FACILITY ID# SERVICE REQUEST# <br /> 12� 30O--� <br /> OWNER/ OPERATOR. _ �n`cia n nl <br /> CJ ,(� CI /dU CHECK If BILLING ADDRESS <br /> - p Or& <br /> FACILITY NAME <br /> SITE ADDRESSp <br /> Street Number I Direction Street Name Ci — Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site dress) <br /> Street Number �����L tgteRJame <br /> CITY 1-T <br /> E ZIP7 ��3 <br /> PHONE 'I EXT. APN# LAND USE APPLICATION# <br /> PHORE 2 N EXT. BOS DISTRICT LOCATION CODE <br /> -7 -v <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR LCHECK If BILLING ADDRESS <br /> BUSINESS NAME P N <br /> Exr. <br /> HOME or MAILING DDRESS ' FAX#ms ) ' <br /> e <br /> CITY ZIP <br /> BILLING ACICN VLEDGEMENT: 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 or <br /> 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 withall AN JOAQUIN <br /> d� <br /> COUNTY Ordinance Codes,Standards )TATFd FEDE S. s <br /> APPLICANT'S SIGNATURE: C DATE: , <br /> PROPERTY/BUSINESS ON'NER❑ OPERATOR/NIANAGER ❑ 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. ENT <br /> TYPE OF SERVICE REQUESTED: REGE1v <br /> COMMENTS: <br /> 1 <br /> COU O <br /> OUtN <br /> SAEN�ROEpAPSM�NT <br /> ACCEPTED BY: �' EMPLOYEE#: DATE: { <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> r <br /> Date Service Compl d (if already completed): SERVICE CODE: PIE: <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 />