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SAN JOAQUI*UNTY ENVIRONMENTAL HEALT VIE PARTMENT <br /> SERVICE REQUEST <br /> rType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> G 44 92 <br /> FACILITY NAME l <br /> SITE ADDRESS <br /> Street Number Direction Street Name ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> b Street Number Street Name <br /> CITYC 1)'0(,{ STATE ZIP Z.?e <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> S' JZ= <br /> Y6 - aZZ� I - <br /> PHONE#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 Codes,Standards, STATE an L la s. <br /> APPLICANT'S SIGNATURE: X 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: I y� <br /> COMMENTS: ECV 1\1 p <br /> JUL 2 2 200 <br /> SP'N J NMENTALTM <br /> TN DEP <br /> ACCEPTED <br /> ACCEPTED B tr- � 1:EMPLOYEE#: L! DATE: D <br /> ASSIGNED TO: EMPLOYEE#: OCJt DATE: Q <br /> { <br /> Date Service Completed (if already,completed): SERVICE CODE: PIE: <br /> Fee Amount: �?�' Amount Paid �s` ^�� Payment Date ?(1:Lf�nl <br /> Payment Type Invoice# Check# ���� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />