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SAN JOAQLwUNTY ENVIRONMENTAL HEAL"PARTMENT <br /> ���II SERVICE REQUEST <br /> +-Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> 1 AGILITY NAMEea ,` A <br /> ;) On r <br /> SITE ADDRESS LA) puei(c A <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E'• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS <br /> �l � ExT. <br /> BUSINESS NAME PHONE <br /> o ( ) <br /> HOME or MAILING ADDRESS <br /> FAX# 0 <br /> 1) _ V1 <br /> CITY STATEMR <br /> 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 or <br /> 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 FEDlaws. <br /> lawws. <br /> APPLICANT'S SIGNATURE: ''� WVIX DATE: <br /> �. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT - <br /> If APPLICANT is not the BILLING PARproof 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 /> providedxo <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS:_ <br /> ACCEPTED By- /EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (� P 1 E: � <br /> Fee Amount: `' Amount Paid g Payment Date Gt <br /> Payment Type Invoice# _ Check# �5 Receive By: <br /> 'r".SRIn�'fM�Goldeh Ftotl) <br /> EHD 48-02-025 " <br /> REVISED 11/17/2003 <br />