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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-00 � r <br /> OWNER/OPERATOR <br /> 12 r CHECK if BILLING ADDRESS❑ <br /> a <br /> FACILITY NAME <br /> eato <br /> SITE ADDRESS <br /> � � w <br /> Streat Number Direction Name CI Ti Code <br /> HOME or MAILING ADDR S (If ifferent from Site Address) <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> PHONE#1 , ExT• APN# LAND USE APPLICATION# <br /> PHONE#T Err. BOS DISTRICT LOCATIONGODE <br /> 6-2 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 214- "Ct <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEr^ PHONE# ExT. <br /> a' <br /> HOME Or MAILING ADDR 5 FA # <br /> 13q CzfA <br /> { 1 <br /> CITY ; STATE 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 <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, STAXE and FEDE L 1 S. <br /> APPLICANT'S SIGNATURE: k /' g - DATE: -- <br /> PROPERTY 1 BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICRNT 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. <br /> At— <br /> TYPE OF SERVICE REQUESTED: N'` <br /> COMMENTS: iio <br /> Vv FFB 0 202 <br /> f <br /> H4RflE AR��7Y <br /> �Nr <br /> ACCEPTED BY: EMPLOYEE#: ^j DATE: C <br /> ASSIGNED TO: C EMPLOYEE#: VVi}� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2� P!E: i LID <br /> Fee Amount: (/ - U Amount Paid �, �� Payment Date r t <br /> Payment Type - Invoice# Check# 1z00 Recei4ed By: <br /> EHD 48-02-025 � 7`IIQ�-1 l� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />