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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0��Z2S 5 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS E] <br /> h M 1 RO <br /> FACILITY NAME b ^n �, <br /> SITE ADDRESS CCS( �� U� bZ6 <br /> Street Number Direction Street Name ��C Code <br /> HOME or AILING ADDRESS (If Different from Site Address) <br /> � 'C 1 `t V Street Number Street Name <br /> CITY STATE IP / / <br /> )Z- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> c- G\` on! n CHECK if BILLING ADDRESS <br /> r BUSINESS NAME �^( _'\j "HEXT.��i L 1 � /.� <br /> HOME or MAILING ADDRESS\ lJ FAX## 1 V L <br /> CITY ( ��( l/� r fp' �\ STATE ZIP <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, Sland and FEDERAL,Iaws. <br /> APPLICANT'S SIGNATURE: �/ DATE: ;'7 <br /> PROPERTY/BUSINESS OWNER❑ TO OPERA /MANAG R 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, 1, 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 environent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ant/ irmit is <br /> provided to me or my representative. �( LVED <br /> TYPE OF SERVICE REQUESTED: �'�Q�1 I '�' ' "VL_ ,JUN <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: 7 <br /> ASSIGNED TO: EMPLOYEE M DATE: L <br /> Date Service Completed (if already completed): SERVICE CODE: I Pi E: 1 CPO <br /> Fee Amount:fV 1S2 Amount Pai ��JOL;') Payment Date / ��i 7 <br /> Payment Type _� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />