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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> b V, CHECK if BILLING ADDRESS <br /> FACILITY NAME v <br /> SITE ADDRESSq0 <br /> 133 Street Number Direc io freer Name <br /> 5 �cltv� Zin 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 /> QC)q) 6 3 g. 3 la a, .p-�- 510 -- q- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQuUNR- <br /> CHECK If BILLING ADDRESS <br /> L <br /> BUSIN Ss NAME ' t PHONE# EXT. <br /> HOME Or MAILING ADDRESS' FAX# <br /> I v3 ( ) <br /> CITY —�J „ Q ��_ STATE ZIP 953 <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: `�� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTIIER AUTIIORI'ZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 and at the same ti0, is <br /> provided to me or my representative. �4F TYPE OF SERVICE REQUESTED; z1 <br /> COMMENTS: }\vim 1/ <br /> 1 <br /> '�VM9Ro�/�y8 <br /> �9Cny�Fp,AFH Nry <br /> HT <br /> ACCEPTED BY: t/ S EMPLOYEE#: <br /> ASSIGNED TO: /✓� EMPLOYEE#: DATE: 0 <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I E: <br /> Fee Amount: l 2 Amount Paid / Payment Date 2� <br /> Payment Type Invoice# Check# Received By: xr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />