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SAN JOAQUIN NTY ENVIRONMENTAL HEALTH UmbPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9110 to 17o1--� S93 . <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> G <br /> FACILITY NAME <br /> Ilura ;9- <br /> SITE ADDRESS u� <br /> S0 V Street Number Direction J Street Name L Cit Zi Code <br /> HOME 0r MAILING ADDRESS (If Different from Site Address) <br /> (7 Street Number Street Name <br /> CITY / STATE ZIP <br /> G1 GA Z-1 6-" <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> 36PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS 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 Costes,Standards, STATE an L la 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 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: - �1 k J Aw t A <br /> COMMENTS: <br /> ACCEPTED BT EMPLOYEE#: DATE: <br /> ASSIGNED TO: t( EMPLOYEE#: o C.� DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PCE: <br /> Fee Amount: ��" Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />