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a <br /> SAN JOAQUVOUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS `� � •33(n <br /> Street Number Direction Street Name Ci i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C1 Street Number Street Name <br /> CITY STATE ZIP S�n <br /> PHONE#1Ex <br /> T APN# LAND USE APPLICATION# <br /> PHONE#TT• BOS DISTRICT LOCATION ODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> \ \�� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADORE FAX# <br /> o (°►l�) 3-73 - V-(3 <br /> CITY ' - STATE ,n ZIP cvq 1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /i (.9- l 3-O� <br /> PROPERTY/BUSINESS OWNER 13OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® l <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS: �� <br /> Jury 16 200 I � 6 � <br /> N. <br /> EWIfiON �ENT NUSN C <br /> MEN- n' <br /> �fiiT SER'ft OEPAR AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 2 Q <br /> Fee Amount: Amount Paid '�q 1,1 Payment Date b UI? <br /> Payment Type Invoice# Check# ?J s d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />