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SAN JoAQu <br /> OUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,e-L' <br /> N R OPERA OR <br /> N <br /> (,,. k)Q d S e� /)/ CHECK If BILLING ADORES <br /> F AME I®1 j] '] <br /> U <br /> SITE ADDPEOR ' ® 1 'T" Q , n q 7 J 6 <br /> 5Cstreet Number Direc Ion 6 Str 'toNam cily Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) f <br /> Street Number ) Street Nam/e <br /> CITY 1 S T ZIP <br /> Uci <br /> iV <br /> _PRO 1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE0I IFcrno <br /> CHECK If BILLING ADDRESS <br /> �WCIL1Cce wl wsac _ A ., P�py�#)-3Q3- / — EXT <br /> HOo Mw iNGI!RESS <br /> pLMA k) <br /> CITY Q.NI, st!5`T ZIP I -T IJ�. t <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: NDATE: ( (' — 0s <br /> PROPERTY/BUSINESS OWNER 13 RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ®1 <br /> If APPLicANT is not the BILLING PARTY,proof of authorization to sign is required <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 environmentaVsite 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 /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <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 /> 13 <br />