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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVI E QUEST# <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> V �� <br /> SITEADDRESS n `�`� oiSZoS <br /> Street Number Direction / C` treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION>CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> HOME or MAILING ADDRESS 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1 <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: � � 5� �K <br /> COMMENTS: S ee V\c C �1ZS� � vv�� CV �V��'✓p��� U`4\ <br /> ACCEPTED BY: M 0.� EMPLOYEE#: l000 DATE: 22t <br /> ASSIGNED TO: I ` u EMPLOYEE#: �600 DATE: 177,( �3 <br /> Date Service Completed (if already completed): L a2a(�7 SERVICE CODE: P IE: `tZ llt) <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 J� <br />