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SAN JOAQUIN46UNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> T pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �oevv 3794s <br /> OW OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME '1 n <br /> SITE DRESS <br /> Street Number OTre'ctio. Street NU `- Zi C � <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SStreet Number Street Name <br /> CITY I STATE I <br /> CA 4P ft <br /> PHONE �l EXT. APN# LAND USE APPLICATION# <br /> "�q!5-I,A <br /> P ONE 2 EXT. BCIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAM PHO E Exr. <br /> '�L <br /> HOME or MAILING ADDRESS F" FAX# <br /> JIA 001 <br /> CITY I V - ATE ZIP <br /> BILLING ACKNOWLEDGE ENT: 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepare s application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rds, STATE and FEDERAL laws. <br /> 11 � <br /> APPLICANT'S SIGNATURE: 1 DATE: P4 A <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT . <br /> IfAPPLICANT 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: PAYMENT <br /> COMMENTS: <br /> MAY 10 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Z. <br /> ACCEPTED BY: EMPLOYEE#: DATE: a C� <br /> ASSIGNED TO: f�,e EMPLOYEE#: C DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: / P/E: 3 Zj <br /> Fee Amount: �7 Amount Paid. `Z Payment Date / 4.J 1,91ze <br /> Payment Type Invoice# Check#�' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />