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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 <br /> /7 \ <br /> FACILITY NAME _\l <br /> SITE ADDRES <br /> l .l �i / ,C . <br /> / t ber irection et e /C I J7 Cod <br /> HOME or MAILINGADDRESS (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. BOS DISTRICT LOCATION ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> . ;DR , <br /> / CHECK If BILLING ADDRESS <br /> Busw6ss N!#W HONE# 7 EXT. <br /> Ho `or MAWN ADDRESS Fax# <br /> CITY �7 T E zip <br /> BILLING-"'ACKNOWLED'GEMENT: 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 t)}is'application al t t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,�nidlards, an F D /an F D laws. <br /> APPLICANT'S SIGNA;rtRE: C DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGE <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title ��: , <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property loca§" <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit e's"��HSCessfinei t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT'as soon as it is available and at t1Leime untie <br /> provided to me or my representative. JJ Jpq Q <br /> � Rp CO, <br /> ( <br /> TYPE OF SERVICE REQUESTED: �S � (,( '-T t J� �iT/Y NMFNTN�. <br /> COMMENTS:V) V e ht- / 1 J MHT <br /> ln/eIIS -�� nrdP2��� �i1� GfS �I ZfSD-� <br /> A)O • 4� <br /> �• � <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: S /C` Z oe O <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P1 E: ya <br /> Amount Pai ent DateFeeAmount: S <br /> Payment Type Invoice# Check# Received By� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />