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SAN JOAQUI ��(-'%UNTY ENVIRONMENTAL HEALTI i�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> "72-C k! <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS A <br /> Street Number ii Direction Street Name .'city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) - ) � <br /> Street N -Street Name <br /> CITY STATE l zip <br /> PHONE#1 Ext. APN# LAND USE APPLICATION <br /> PHONE#2 EXT- <br /> F <br /> BOS DISTRICT OC15ATLON CODE <br /> :5— -- - <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR Z <br /> CHECK if BILLING ADDRESS <br /> n , <br /> BUSINESS NAME PHONE# EXT. <br /> Zx- <br /> HOME or MAILING ADDRESS FAx <br /> J <br /> CITY f STATE tzip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTNIFNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> f 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 andFEDERALlaws, <br /> APPLICANT'S SIGNATURE: 4- f DATE: <br /> ,o�' E <br /> PROPER rv/BUSINLSSOWNEREI 4' 0PER-4TOR1JNl(%NAGER 1:1 OTHER AUTHORIZED AGENT E, <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 and at the same time it is <br /> provided to Me OF In V representative. <br /> TYPE OF SERVICE REQUESTED: L. <br /> CCMMENTS: <br /> jN coui,ITY <br /> SAN ic)"�Q <br /> FN,JJRONNIE N7A'— <br /> Ff r;;7-H DEPAHrPF--'N1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /\"-+I /9 �-t- EMPLOYEE 2 DATE: C. <br /> Date Service Completed (if already completed): SERVICE CODE P I E: <br /> �-) Payment Date <br /> D <br /> I <br /> Fee Amount: :# �(; <br /> Amount Paid _, t_--, <br /> Payment Type Invoice# Check# Received BY: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 1111712003 <br />