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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAX # <br />CITY STATE ZIP <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: G ] <br />OWNER / OPERATOR <br />� <br />� <br />CHECK If BILLING ADDRESS ❑ <br />v <br />✓ ` ` <br />SERVICE CODE:: Vii. <br />, <br />FACILITY NAME <br />Fee Amount: <br />Amount <br />SITE ADDRESS �0J.� <br />6 J 3 Street Number <br />Direction <br />Payment Type <br />1 Street Name <br />Check # <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I7 O 4 g O S—I Li <br />Street Number <br />Street Name <br />CITY �] <br />STATE <br />_ZIP <br />PHyON�Eq#1 EXT. <br />Goa— ,3��� <br />APN # j <br />�����10_1 —7 <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR i <br />REQUESTOR ':;' CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY 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 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �A,..R <br />DATE: 24 A �� <br />PROPERTY/ BUSINESS OWNER ❑ OPAGER ❑ 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: CjTtz7 <br />�� G C I <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: G ] <br />ASSIGNED TO:f( <br />EMPLOYEE #: <br />DATE: <br />l <br />Date Service Completed (if already completed): p_ t 1 <br />—Plaid 1 <br />SERVICE CODE:: Vii. <br />, <br />p / E: <br />Fee Amount: <br />Amount <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 />