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I <br /> SAN JOAQUIOCOUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prope FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Q <br /> Street Number Direction tree Name CIt Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Z S° a� - 4-f- <br /> PHONE#1EXT• APN# LAND USE APPLICATION# <br /> ( ) C) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> _ /_ CHECK if BILLING ADDRESS'' <br /> —4 t . <br /> BUSINESS NAME / PHONE# EXT' <br /> (Zo e73 2>l(d <br /> HOME or MAILING ADDRESS FAX# <br /> TGA (2a 1 9�i-U7 3 y <br /> CITY STATE ZIP Q f / <br /> r l�✓ / G� <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 EwRoNmENTAL 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, TA d FEDERAL v s. <br /> APPLICANT'S SIGNATURE: ` DATE: <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 environme to assessment <br /> information to the SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT as soon as it is available and'of .p, e it is <br /> provided to me or my representative. C <br /> TYPE OF SERVICE REQUESTED: LOAArAN <br /> COMMENTS: kujq <br /> 0vtN C© <br /> q�TM�N ry . <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G EMPLOYEE#: DATE: <br /> Date Service Completed (if already Compl ted): SERVICE CODE: P/E: <br /> Fee Amount: d 0 Amount Paid, �5d�pD Payment Date j <br /> Payment Type Invoice# Check# 3-7S;2- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />