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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST (1) o`1 cis3 - Tic q 7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR �L <br /> /r CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SIT'ADI SS iv /L / G /G L LJ�>�; . <br /> Street Number i r e C Zi Cod <br /> H E or AILING ADDRE � (if Different from Sit Address) <br /> � � `� w1 sr3!GI `L Street Number Street Name <br /> CITY /lJ^- ` STATEy• <br /> PHO .#1 '� ( EXT AP / LAND`USE rJAPPLICATION# ) <br /> -2— <br /> PHONE#2 EXT. BOS DISTRICTLOCODE 711 <br /> ( ) 7CATION <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> PAS <br /> HOME or MAILING ADDRESS FAX# If <br /> , �� <br /> ( ) <br /> CITY STATE ZIP N r <br /> Z-EBILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize Asam 20 <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associak6�Jq <br /> or activity will be billed to me or my business as identified on this form. OEpq � <br /> T <br /> I also certify that I have prepared this a ation and that the work to e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER Ef OTHER AUTHORIZED AGENT❑ <br /> If 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 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 /> COMMENTS: <br /> Oe bit,dc. <br /> ACCEPTED BY: EMPLOYEE#: DATE: / .7J D <br /> ASSIGNED TO: J EMPLOYEE#: DATE: LdOd 0 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: Ll 3,D <br /> FeeAmount: s a Amount Pai /S-�2 06 Payment Date P <br /> Payment Type ` Invoice# Check# �� 8 7 7�� eceiv�d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />