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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTSEPARTMENT <br /> r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a-'J by <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILm'NAME <br /> raoaParav�/ <br /> SITEStreet <br /> I7 �S <br /> t a Street Number D.—tion t ame Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONEY ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REqUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> e <br /> HOMEt MAILI ADDRESS FAX#0 64 x 10 ) <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,Standar TE and FEDE ws. <br /> i <br /> APPLICANT'S SIGNATU DATE; 7 /6j� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof o authorizadon 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: C c� ' t <br /> COMMENTS: ..S � ` J�� <br /> _ <br /> � 152008 <br /> SA ENVIRONMENTAL <br /> AQUINOUNTy <br /> HEALTH DEPARTENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t I?�l P/E: <br /> Fee Amount: Amount Paid -a c�gt, 6 Q Payment to <br /> Payment Type S '-� invoice# Check# Received By: N( ; -- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />