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SAN JOh4 COUN_ 1 ENVIRONMENTAL HEA DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ,..Y C\ _ ^ � ` ( 1� � CK If BILLING ADDRESS <br /> FACILITY NAME i <br /> mhw-1 <br /> SITE ADDRESS <br /> Street Number Direction Street Narr <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME1� EXT. <br /> '.. � PyQNE <br /> HOME Of 33 MAILING-ADnRFS CL 1 �1 (� ) W —�1 <br /> � f <br /> CITY I \�Nt STA zip C_ <br /> BILLLNG ACKNOWL DGEMENT: 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 a entified on this form. <br /> I also certify that I have prepared this a i tion and t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , ST E E WS. <br /> APPLICANT'S SIGNATURE: `f/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT i 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 aIl`d the Srt1�.time it is <br /> provided to me or my representative. 1 <br /> TYPE OF SERVICE REQUESTED: V 1 J (O S r <br /> COMMENTS: 2 m4 <br /> �( <br /> 4h SAN JOAQUIN COUNTY <br /> L� ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: q ' ` EMPLOYEE#: DATE: <br /> 01 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: Z/ <br /> Fee Amount: Lkos.oa Amount Paid !f Payment Date <br /> L <br /> Payment Type Invoice# Check#,-y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />