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SAN JOAQtIIN COUNTY ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ono 7- ��- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME � >2—/ <br /> SITE <br /> SITE ADDRESS <br /> Stfeet Number Direction Street Name Cit< 7 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY / STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> -0 <br /> BUSINESS NAME PHONE# EXT. <br /> 341-23��2 <br /> HOME or MAILING ADD SS FAX# <br /> (� ) 333ey 2 -7 <br /> CITY _�1. STAT 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 or <br /> 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, STAT TEAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEn AGEN� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required��JJJJ 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 enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAt.i'H 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: P� �YA 41 <br /> /� N <br /> �VED <br /> �e 232009 <br /> `a� �� RONMAO <br /> E OV NN <br /> ACCEPl`EDtY° Lo 5,tl EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: z2, PIE. <br /> Fee Amount: Zl Amount Paid Payment Date 0 <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />