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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> fA �I 0 S A 1. (0 0 (� OG��v CHECK if BILLING ADDRESS <br /> 1 v` <br /> FACILITY NAME cc 1 f e.os l rC�ArL L <br /> SITE ADDRESS Z V cJ�. 3 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ZS-3LA �„-- S- <br /> Street Number Street Name <br /> CITY STATE C ZIP <br /> PHONE#') ExT. APN# LAND USE APPLICATION# <br /> (°�) c am- �.2G <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 /> 1 also certify that I have prepared this application and that the work to be performe ill be done'in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FED AL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 a at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �O <br /> COMMENTS: <br /> f 1�j n J� Oka�J / \�(I ReG1 M �G <br /> v` l' 20 <br /> 20 <br /> p.4oUhVC% <br /> ZAL7hDFp P��ry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: ,�2� Amount Paid �S� j>� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />