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SAN JOAQU- —'OUNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6 b es <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESX1 <br /> lI I / <br /> FACILITY NAME <br /> SITE ADDRESS IC -701 �� �� O�� �� 5�, <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) c <br /> rfttsh <br /> C Street Number J t Name <br /> CITY <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (,k l ) C C/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <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 <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, STATE and F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 /> t•►,H1Nn Rp M�r(AL <br /> rtFJ�TH own <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: h EMPLOYEE#: DATE: V—t 411 <br /> Date Service Completed (if already completed): SERVICE CODE: 06 P I E: v <br /> Fee Amount: 10 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-023 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />