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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ou � 1� 3 <br /> OWNER/O E OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name citv Zip Code <br /> or MAILING ADS (If D' Brent from Site A est) <br /> / li L/�1f Street Number Street Name <br /> CITY Sr E 4 ZIP _ <br /> PHONE#f k ExT• APN# LAND USE APPLICATION# <br /> O <br /> -0(301 <br /> PHONE#2 <br /> 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 "- n�( FAX# <br /> CITY STATE ZIP 9 <br /> BILLING ACKNOWLED EMENT: 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 a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T E and FED <br /> SERA laws. <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 prop located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenn�����_ i�►MSSessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and aR[I > is <br /> provided to me or my representative. `` � <br /> TYPE OF SERVICE REQUESTED: l� Cin R <br /> COMMENTS: j 1 c ^ „ _„� �`n _ y FjUOgQ��H <br /> COU <br /> MFHT <br /> ACCEPTED BY: Y Y l 011 n e n EMPLOYEE#: DATE: 3 I� <br /> ASSIGNED TO: Cj ��svn Av �l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: V SZ_ Amount Paq�5/5') 'DD Payment Date 3/13/2n <br /> Payment TypeInvoice# Check# Recel'ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />