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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�" 2 <br /> OWNER I OPERATORU <br /> ,I o 1 U CHECK If BILLING ADDRE55O <br /> FACILITY NAME 1 <br /> SITE ADDRESSn S'--/�11 5 4u( <br /> Street Nutuber Duction —s treat Name City Zip Cone <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> YO0r J Street Number treet Name <br /> CITY STATE ZIP <br /> '*o C C 1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# It <br /> PHONIER EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME _ PHONE# EXT, <br /> �Nyocjlze \ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C STATE ZIP Qc <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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, ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:/ \ q I11I2C1 <br /> PROPERTY/BUSINESS OWNER "OR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not t 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 a hef9116ie time it is <br /> provided to me or my representative. Kr "fret) <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: cl� CJ`Ep <br /> SANJOA <br /> Hv<.TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: _ S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ow PIE:NO 0 Z <br /> Fee Amount: �Pt 5- Amount Paid �S Z Payment Date 2t yp� <br /> Payment Type ti�s� Invoice# Check# �l 3�v Received By1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />