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SAN JOAkZ AN COUNTY ENVIRONMENTAL HEAL.d DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f n <br /> 66N <br /> OWNER/OPERATOR <br /> �JILLINGADDRESS� <br /> FACILITY NAMEv --� <br /> S 6— <br /> SITE ADDRESS 4' <br /> �� s� <br /> eel Number Dire tion ree Name Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street NumberameU rr <br /> CITY STATE C—/q ZIP <br /> PHONE#1EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 <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. j <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 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: <br /> COMMENTS: L / APU /VF„ <br /> G SqN Jo <br /> -41t �0 CO <br /> ggTM� <br /> r ci <br /> ACCEPTED BY: EMPLOYEE#: '�6 "7 0 DATE; <br /> ASSIGNED TO: EMPLOYEE#: > DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ) PIE: 7 <br /> Fee Amount: - �'" Amount Paid r:„,„ . Payment to <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />