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SAN JOAQUIN COUNTY ENwRoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 5.1,.,,�•,a� clstZ o <br /> G -treecN 'v city v <br /> ��0 Street Number Direction / Street Nle Ci Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#; ExT. AP 1 1 LAND USE APPLICATION# <br /> v O <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( , OO o� <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 enviromnental/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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 'GV-\/.CJIL th�S1 f p✓ j"1�.t. �0 v n S�4 �L cwt C�S�I T`P�0 /� <br /> 4 N Jf /! Y.[+iT �A•Mv�nv.w��� -��✓ S -"iY=�L-�'= r'�-� O✓� t 1�v� -1��{a) <br /> ACCEPTED BY: \% EMPLOYEE#: DATE:0 10?1i S /L I <br /> ASSIGNED TO: O EMPLOYEE#: O 2 DATE: •3 1 c' I <br /> Date Service Completed (if alr ady completed): SERVICE CODE: P/E: `17 4 0 <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 />