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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID.#_^ � ERVOICE Rf=QUST#,t <br /> 0 <br /> OWNER/OPRATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> a Gt <br /> SITE ADDRESS <br /> Street Number I Direction l Street Name 1, Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 'cl q <br /> Street Number W Street Name <br /> CITY /�/�aq I STATE`� ZIP �5Z <br /> PHONE#t V �In•`-i`r � EXT- APN# LAND USE 1APPLICATION# l <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR } <br /> Am� <br /> IV„\ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILINGDDRESS FAX# <br /> W.. ( ) <br /> CITY STATE ZIP p� <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:'LMM S (jDATE: <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. A <br /> TYPE OF SERVICE REQUESTED: cm S E'CF <br /> COMMENTS: <br /> SAN jQAQL/ <br /> CNV/ NM Cp N <br /> HFACryDZPA�- �Y <br /> r <br /> ACCEPTED BY: r EMPLOYEE#: ,[ DATE: <br /> ASSIGNED TO: I EMPLOYEE#: v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:1 Q3 <br /> l <br /> Fee Amount: U� Amount Paid a Payment Date 2 2 e 1-2 6 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />