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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />C) ,Zj <br />COMMENTS: <br />SERVICE REQUEST # <br />171 (os� <br />OWNER! OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />� C <br />FAx <br /># �I'&3�'Z <br />SITE ADDRESS BG\ <br />Street Number <br />Direction <br />I Cam <br />C )street Name <br />CITY <br />Lmk <br />�� Ci <br />(t b2,*) <br />l` <br />I Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />L / <br />Street Name <br />CITY <br />DATE: <br />STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />/A <br />SERVICE CODE: <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PHO EXT' <br />R� <br />'_ <br />HOME or MAILING ADDRESS � <br />,� <br />FAx <br /># �I'&3�'Z <br />COU8 <br />\t1MRON <br />CITY <br />STATE m ZIP 95 <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 FEDERAL laws. �Q Q <br />APPLICANT'S SIGNATURE:1) DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ 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. <br />TYPE OF SERVICE REQUESTED: I <br />ppYMETA <br />COMMENTS: <br />R� <br />� 2012 <br />�uN r <br />COU8 <br />\t1MRON <br />H�-TM pEMapT1A!'t <br />ACCEPTED BY: , <br />EMPLOYEE #: <br />EMPLOYEE #: <br />L / <br />DATE: <br />ASSIGNED TO: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />