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SAN JOAQUIN COUNTY ENVIRONMENTAL HEATH DEPARTMENT l 3_,��� <br /> SERVICE REQUESTI>1sp�cti�>n "��(���9 �1 /7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS L/� <br /> Street Number Dlrectlon Street Name CIt Zip Code <br /> HOMEro MAILING ADDRESS&,Ififferent from Site Address) <br /> Street Number Street Name <br /> CITY�\ _ C� \ $TAzE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> <{ A 0e% 700/'0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR P <br /> REQUESTORR; < C L /� / ` / C �._' CHECK If BILLINP�C BUSINESS NAMEVPHONE# �E r. <br /> �o <br /> HOME or MAILING ADDRESS / FAX# ENVtAQIjfly CO <br /> CITY STATE ZIP RTMFNT <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,Standa ds S TE and=- s. <br /> /1 <br /> APPLICANT'S SIGNATURE: DATE: <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, 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 time it is <br /> provided to me or my representative. j <br /> TYPE OF SERVICE REQUESTED: ,I�� g <br /> COMMENTS: r <br /> r�s-hoo�'''► yobt✓ CcArrEc4 rio �P�'� Ic. ��� oc)sj 72y' -7 '-1 <br /> Ss'J <br /> r <br /> ��f i►�s�;�c:�l;,� C�;II �,flG, �fS3. 7�c17� yg �ou�' c,�,Ivcir�cP� e <br /> ACCEPTED BY: L✓ EMPLOYEE#: DATE: <br /> ASSIGNED TO: DA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O�, P I E: 1�a 0c; <br /> Fee Amount: Amount Paid 11 ;� /) Payment Date <br /> Payment Type Invoice# Check# cpReceived By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />