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SAN JOAN_.w COUNTY ENVIRONMENTAL HEAL_... DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR 5t t ► � ` <br /> I►V, CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � 4� <br /> Streett Number Direction Street Name it Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) JI <br /> Street Number <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 2v 7) L( <br /> PHONE#2 �P ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <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. <br /> APPLICANT'S SIGNATURE: hj � �[i� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1CANT is not the B1amgPARTY,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 environ; trent I/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anit is <br /> provided to me or my representative. _ C IV r <br /> TYPE OF SERVICE REQUESTED: Y1 APR j <br /> COMMENTS: AN X <br /> 11, I <br /> qMF�1O NNTT <br /> yqNDAq <br /> ACCEPTED <br /> BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE:Gc P 1 E: <br /> Fee Amount: z i Amount Paid /ay U D Payment Date <br /> Payment Type �� Invoice# Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />