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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> �3Co�l <br /> O ER / OPERATOR / <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS 1 <br /> J , <br /> Street Number Direction Street Name Cit ` Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE #f EXT• APN # LAND% USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> s /. ) � ! r � J CHECK If BILLING ADDRESS <br /> 14 BUSINESS NAME PHONE # EXT. <br /> HOME or MAILING ADDRESS FAX # <br /> CITYSTATE ZIP `� , N <br /> L <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 , y j <br /> PPLICANT ' S SIGNATURE : 7 ) DATE : / 27//2 0 7 1 <br /> PROPERTY / BUSINESS OWNER El OPERATOR / NAGER ❑ OTHER AUTHORIZED AGENT El <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 th me it is <br /> provided to tme or my representative . pAY � <br /> TYPE OF SERVICE REQUESTED : �) fl"/ 60/1 RSC <br /> COMMENTS : <br /> APR 2 7 %L® <br /> SAN V '0t4M WTJ%L <br /> ENVIRONMENTAL <br /> G " ' ���G 1�C HEALTH DE <br /> ACCEPTED BY: EMPLOYEE # : DATE : 2� / <br /> l,Gl I� 2 <br /> ASSIGNED TO : EMPLOYEE # : DATE : <br /> Date Service Completed ( if already Completed) : SERVICE CODE : PIE : <br /> Fee Amount : /, Amount Paid 5 Payment Date ll <br /> v � l <br /> Payment Type Invoice # Check # Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />