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SAN JOAQUI*UNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST 3� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAW <br /> SITE ADDRESS /r��' � <br /> Street Number Direction Street�a�inlVe Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site AddNess) <br /> t.L`Sj C "Cv DIGS �'� (037 <br /> u t � 2 Street Number Street Name <br /> CITY J� � STATE/" /I ZIP <br /> PHONE#1 EXT. APN# LAND USE/APPLICATION# <br /> PHONE#2 EXT. BOS11 DISTRICT OCATION CO <br /> LD <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ CHECK If BILLING ADDRESS❑ <br /> BUSINESS AME PHONE# EXT. <br /> HOME or MA LING Ak6RESS FAX# <br /> CITY 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 or <br /> 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: DATE: 31e <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER , 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 /> ACCEPTED BY' EMPLOYEE#: 5—��� DATE: <br /> ASSIGNED TO: / EMPLOYEE#: � DATE: c� (Slo <br /> Date Service Completed (if alread ompleted): SERVICE CODE: ,�y s <br /> Fee Amount: �j- Amount Paid Payment Date "T, J <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />