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SAN JOAQ COUNTY ENVIRONMENTAL HEALT EPARTMENT <br />Type of Business or Property <br />Q6S <br />FACILITY IID `# <br />PHONE # EXT. <br />SERVICE REQUEST <br />VL <br />OWNER/ OPERATOR <br />CITY STATE ZIP <br />CHECK if BILLING ADDRESS <br />FACILITY NAME C' <br />S <br />ASSIGNED TO: <br />E ADDRESS <br />v Su®t NumberFQJ2�n <br />EMPLOYEE #: <br />t <br />I <br />Date Service Completed (if already completed): <br />Code d1ere <br />HOME Or AILING ADDRESS (If Different from Site dressesC� �* _ n e, <br />Str et Number G SAO Name <br />CITY <br />aJ® ._ <br />STATE zip <br />PHONE #1 ExT• <br />-77 <br />7# <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />Received By: <br />BOS DISTRIC <br />LOCA ON ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />RILLINg AMQWLERgEMFgN1: 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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an FEDE L laws. <br />APPLICANT'S SIGNATURE:_ DATE: C 7/ ,), <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ ;WAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPL/CANT is not the BILLING PARTY. proof of authorization to sign is required Title <br />AUTIIQR:IZATIQN TQ RELEASE INFQRMAA;.TIQN: 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. PA <br />TYPE OF SERVICE REQUESTED: ( <br />RECEIVED <br />COMMENTS: <br />JAN ® 7 GUI � <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: a <br />EMPLOYEE #: <br />DATE: g <br />Lh <br />S <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: C> <br />PIE: 'Z <br />Fee Amount: 'rj (: <br />Amount Paid <br />aJ® ._ <br />Payment Date ( '-1 _— <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />