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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -F <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction (=- � Street Name CittV ` Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 FYT_ ACM ff LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> REQUESTOR CHECK ifBILLINGADDRESS <br /> � <br /> BUSINESS NAME PHONE# EXT' <br /> -s�. <br /> HOME Or MAILING AD 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 El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> JfAPPLICANT 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 environmentaUsite 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: V-x-S e— <br /> COMMENTS:5Ccv 4C Q 'feg VGgV ,rvSeeck cry\ VV��hSen�C VLk3V <br /> ov��ctic\:�C �t �� Ao -\,(-CvCA �vvp l aXy C i Z 4C) <br /> ACCEPTED BY: EMPLOYEE M q foo DATE: <br /> ASSIGNED TO: J�/t �- EMPLOYEE#: DATE: A 7 tV5 <br /> Date Service Completed'(if already completed): / SERVICE CODE: �� P E: \i?U t� <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 <br />