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SAN JOAQUIN*UNTY ENVIRONMENTAL HEALTH�PARTMENT <br /> SERVICE REQUEST <br /> Te of Bus��ne IsIss-or Property FACILITY ID# SERVICE REQUEST# <br /> r, <br /> K) � 'o' <br /> O ER/ OPERATOR&V <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME Of�)L <br /> SITE AD`� <br /> Street Number Dir e WV <br /> —" Gi Zi Code <br /> HOME or MAILING ADDRESS DDi eren roite Add r� s) <br /> Street Number Street Name <br /> CITY 44 hn N - 2 S:U80`Z ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 6 ) 6-7- <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REGtUESTOR tu CHECK If BILLING ADDRESS <br /> -Xi 11 <br /> 14 <br /> BUSINESS NAME ► PHONE / ExT. <br /> / ) 1 <br /> HOME or MAILING ADDRESS r/i Y FAX# <br /> tU/I (rvq 3z-/2 <br /> CITY ) fo 7 STAT ZIP �0 <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,Standar STATE and F DE L laws. <br /> IAI L <br /> APPLICANT'S SIGNATURE: ftu DATE: �jQD ' f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El 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 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. pAYMENT <br /> TYPE OF SERVICE REQUESTED: Ze <br /> 2 PON <br /> [� <br /> COMMENTS: MA►e <br /> SAN JOAOUIN COUNTr <br /> NVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �)�t EMPLOYEE#: D DATE: ,07 © (� <br /> ASSIGNED TO: r L EMPLOYEE#: ' DATE: -3 2( <br /> Date Service Completed (if already completed): SERVICE CODE: ct'Z P) <br /> Fee Amount: L Amount Paid ��_ Payment Date '� ( wv <br /> Payment Type Invoice# Check# g"?Z�?� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />