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SAN JOAQUT" '-'OUNTY ENVIRONMENTAL HEAL— - DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS C T OKf►'/ ST <br /> ri) <br /> Street Number Direction Street Name L Of C Ci e16 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> A,,\C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. ApN# LAND USE APPLICATION# <br /> rPHNE#T < ExT• BOS DISTRICT LOCATION CODE <br /> zq <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME _ _ ExT <br /> PH��# ' IE 13 <br /> HOME or MAILING ADDRESS FAX# <br /> Zo <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 and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: d + <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. T <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 8 m5 <br /> 'AIA JoAou'N oouNN <br /> DEP R-TMEN <br /> HEA THON IAL T <br /> 1 <br /> ACCEPTED BY: 9 G EMPLOYEE#: i r.' l i DATE: C. <br /> l /r <br /> ASSIGNED TO: _ I, __` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date g �c)5 <br /> Payment Type Invoice# Check# Received By: <br />