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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 /> CHECK if BILLING ADDRESS 13 <br /> FACILITY NAME G <br /> '7 6o <br /> SITE ADDRESS (v1 tr <br /> Street Number r Na i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street <br /> CITY STATE zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTO <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> -Try- 'fug i <br /> HOME or MAILING ADDRESS FAX# <br /> Z�uznn ( Us) /3_GU/ <br /> CITY S F Il s Cbl 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: ,L",I. /„J2'S" DATE/ <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proOfCOf 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. 1 <br /> TYPE OF SERVICE REQUESTED: C - <br /> COMMENTS: PAYME <br /> ECFV <br /> MAR 3 1 2(11 <br /> s„s>Jo9ai!rN Cu I Fy <br /> tiT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com ted (if aready completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />