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SAN JOAOMMI&OUNTY ENVIRONMENTAL HEAJ1MVJ2EPARTMENT <br />SERVICE REQUEST <br />Typeof Business or Pro <br />rty <br />FACILITY ID # <br />SERVICE REQUEST <br />OWNER I O RATOR <br />MA <br />CHECK if BILLING ADDRESS <br />- - <br />fACILRY NAME <br />SC[E ADM—Street Number <br />D irectionStreet <br />N t <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />`Y Street Number <br />STATE <br />f <br />tree ame �l j' <br />zip <br />EM, APN # LAND USE APPLICATION # <br />PHONE#22EX''• BOS DISTRICT <br />LOCATION CODE <br />g� 0� <br />CONTRACTOR SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS <br />REQUESTOR <br />BUSINESS NAME', <br />P ON <br />Exr. <br />2 <br />HMAILING DDREOMEor <br />-�- ( s r <br />FAX # <br />f tpj <br />— - — -- _- STATE ZIP <br />CITY <br />jl G ACKNO E T: 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 prepared this app c tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST T and FEDE$AL la <br />APPLICANT'S SIGNATURE: ! DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Q•/�K <br />IfAPPL7CANT is not the BILLING PARTY proof of authorization to sign is required Titte <br />AITTHORIZATION 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: <br />OMMENTS <br />-- -ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />SERVICE CODE: PIE: <br />Date Service Completed (if already completed): <br />Fee Amount: Amount Paid Payment Date <br />'Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />