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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR � _ / n 1 L Y 0��/ {1�C�L CHECK If BILLING ADDRESS E] <br /> FACILITY NAME �Y ' 1 <br /> SITE ADDRESS U <br /> ( $ <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDR S (If Different from Pite Address) <br /> C-4,�I'd Street Number <br /> Street Name <br /> CITY ^ STATE 2) ZIP <br /> PHONF41 ExT. APN# LAND USE APPLICATION# <br /> (Zc' <br /> 2- <br /> P <br /> P E ExT. BOS DISTRICT LOCATiON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# ExT. <br /> HO or MAILING ADDRESS FAx# <br /> l ) <br /> CITY STATE ZIP <br /> 13I1LL'ING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknm, ledge 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 busm s identified on this form. <br /> I also certify that I have prepared thipp 'cati, nd that t rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , ST E nd D I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPE OR AGER ❑ OTHER AUTHORIZED AGENT❑ C (5 t NI <br /> P c <br /> If AYPL/CAN is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: 'L <br /> COMMENTS: <br /> JUL 12 <br /> V <br /> SAN JO 2�1} <br /> � <br /> ENVIR$UIN COON <br /> HEAL?}i DPgRTMEN-r <br /> ACCEPTED BY: EMPLOYEE#: CJ DATE:. , <br /> _ G <br /> ASSIGNED TO. EMPLOYEE#: te— DATE: <br /> Date Service Complet (if already completed): SERVICE CODE: © P, <br /> E: <br /> Fee Amount: Zr'7 Amount Paid Payment Date <br /> Payment Type t Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />