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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> � << � S�"� -h � � ►�1t hi � � � IC�a0�2 O S 8008 137 8 <br /> OWNER / OPERATOR <br /> vi (J CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSI :ib h'l CiN d 1 m c. y <br /> 3q Zq 3 Street Number Direction Street Name C tV Zin Code <br /> HOME or MAILING A SS ( If Different from SI ddress ) <br /> r Z q ► v 1q 1— Street Number Street Name <br /> CITY STAT ZIP <br /> �r a c <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ' TG v%4N t �� 05ei nV CHECK If BILLING ADDRESSO <br /> BUSINESS NAME ° J PHONE # EXT. <br /> `1 eV <br /> y ctx41 T* 70Y 3 <br /> HOME or MAILING ADDRESSrr FAX # <br /> CITY o A ` r STATE ZIP s 3- <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 FEDERAL laws . <br /> APPLICANT' S SIGNATURE : ' � DATE : <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PART)' 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 andt the same time it is <br /> provided to me or my representative . p <br /> TYPE OF SERVICE REQUESTED : �� r <br /> COMMENTS : Nov � � <br /> ZQj9 <br /> CO FN��gQU1N <br /> H�`1CryDFpgRTT�NTY <br /> MFN74 <br /> ACCEPTED BY : \ V � tr�J EMPLOYEE # : DATE : r <br /> ASSIGNED TO : j / 7 ► �' l EMPLOYEE # : DATE : l (� <br /> Date Service Completed ( if already coillpleteuj . SERVICE CODE : OGfg', P / ED <br /> Fee Amount : Amount Paid r Payment Date I <br /> Payment Type Invoice # Check # Received% By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 / 17/2003 <br />