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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 X00 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ste. <br /> SITE ADDRESS ��O <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Exr. APN# I c^^ ` LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOC CODE <br /> ( ) 003 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 /> IfAPPL1CANT is not theBLU,NGPARTY 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. <br /> TYPE OF SERVICE REQUESTED: k+5k .� <br /> COMMENTS:3'wS�ep �\1v. NL. .w' G�1Z '~v^L �. - S� 4v^c.r 4 <br /> 11 <br /> ACCEPTED BY: `v EMPLOYEE#: DATE: ' t <br /> ASSIGNED TO: EMPLOYEE#: HOZ 1 DATE: / 1 J It <br /> Date Service Completed (I already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> 025 SR FORM(Golden Rod) <br /> REVISED <br /> 11117/2003 <br />