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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW /OPE TOR <br /> CHECK If BILLING ADDRES \!i <br /> FACILITY NAME <br /> SITE ADDRES / <br /> 1 1 / t ber Directionet e ` I od <br /> HOME Or MAILING DDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION ODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> �R ;y <br /> � l` CHECK If BILLING ADDRES <br /> USI SS N �s PHONE# -7 EXT' <br /> Ho or r MAiLlN ADDRESS FAX# <br /> CITY T E ZIP —.� •,� <br /> BILLIN ACKNOWLEDGEMENT: 1, 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 a t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, an F D laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 v <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGE <br /> /f APPLICANT 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 Iocateen <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit�7q'�/�Iq9 ssnient <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tl1c�nle' ilril 9 20� <br /> provided to me or my representative. aJ� ✓Oq 0 <br /> TYPE OF SERVICE REQUESTED: S I klri[ry 0NMFNr Nn. <br /> COMMENTS: v`h( / i +S l N✓IC fIR1 I^/e 6 r r^y M NT <br /> 0 r-I'� /0 <br /> itr <br /> o�A . Iffier �1' -�'� o't � t' � 6t'li7 p p✓ef' �to�cr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> / <br /> ASSIGNED TO: s EMPLOYEE#: DATE: S OZ <br /> Z <br /> Date Service Completed (if already completed): SERVICE CODE: 0�� P 1E: yob Q <br /> Fee Amount: S Amount Paid /-�. (IO Payment Date / -71 <br /> 2� <br /> Payment Type,%" Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />