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SAN JOAQUI*UNTY ENVIT4JNMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIIMTY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ()\- v vy-) <br /> SITE ADDRESS <br /> S� rectnio �StreeName <br /> Street Number Di <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7` <br /> reet Number Street Name <br /> CITY StSTATE *AY <br /> (vCb <br /> PHONE#1 EXT. APN# LAND USE APPLICATRl1vON CCN�t �rl1671�/ i�iTU <br /> ( ) <br /> PHONE#2 EXT. PEPF <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY <br /> STATE ZIP 0,5—Z ! <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 proje <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 JOAQUI <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: S �—0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ n [ CR ` [� <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 /> infonnation 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: U pAYf`��1EN I <br /> COMMENTS: <br /> SAN 30A'U"COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ? 211-11 DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2s�J000 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l p/E; O (� <br /> Fee Amount: Amount Paid Payment Date S L� <br /> Payment Type Invoice# Check# <br /> \ � � Received By: � <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />