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SAN JOAQUII OUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAci ITY NAME <br /> SITE ADDRESS <br /> I �S 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 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 1. C (201 ) s y-1- -:3 <br /> Ho r MAILING ADDRESS FAx# <br /> CITY W n, 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 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. <br /> APPLICANT'S SIGNATURE: a t, � ,y��k DATE: a` <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 anti Vme time it is <br /> provided to me or my representative. PA �V�VEP <br /> TYPE OF SERVICE REQUESTED: Tte 4 4 2WA <br /> COMMENTS: V <br /> SAN JOAQU►N COUNTY <br /> ENVIRO ME''ENT <br /> • t{�LTH D <br /> ACCEPTED BY: EMPLOYEE#: �� DATE: <br /> ASSIGNED TO: EMPLOYEE#: �� DATE: <br /> Date Service eompleted (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid 2'' J l- l7 Payment Date <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />