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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ]K;SCERVICE REQUEST# <br /> u I$ <br /> OWNER/O E OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Dir.clion Street Name City Zip Code <br /> Or MAILING AD S (If D event from Site A as <br /> �� Street Number A Street Name <br /> CITY $7gTE ZIP <br /> C CA— <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> Imo) -0qpJ <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ! n h2ilot�J/1w PHONE# EXT' <br /> HOME Or MAILING ADDRESS it l FAX <br /> I ) /r�t <br /> CITY STATE ZIP <br /> BILLING ACKNOWLED EMENT: 1, 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 /> 1 also certify that I have prepared this application and that e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E and FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTnoRIZED AGENT 11 <br /> IfAPPL1CANT is not the BILLING PARTY Proof of authorization to sign is required Tille <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propegy located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmennkoRr/��gpg^es_sment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and �tflN�tis <br /> provided to me or my representative. `Q` �' �_�•II <br /> TYPE OF SERVICE REQUESTED: 7 W CkW% ,�ti rf <br /> 17 1- <br /> COMMENTS: I], T � Ii ,, � k �, � y FNLyOAQUN <br /> CAJ I Y �k' CJYWv� "A NNDON'y" Cou'v Y <br /> FI'; NT <br /> ACCEPTED BY: 11/1(1 i A EMPLOYEE M DATE: 3 I� <br /> ASSIGNED TO: Cj �, VV1•l (J EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: (1 n PIE: I LAS <br /> Fee Amount: V GJZ_ Amount Pat DD Payment Date <br /> Payment Type ���. -f Invoice# Check# �G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />