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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 I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> a 6 <br /> FACILITY NAME <br /> SITEADDREssfS <br /> 71on <br /> Street Number ret ame Clt�D ZI Code <br /> H or MAILI A D ES5 If Different from a Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN LAND USE APPLICATION# <br /> 2� IS3� os ` Sao. 0� <br /> PHONE#2 ExT• BOS DISTRICT LDCATION GODS <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR -A, (� <br /> J� CHECK if BILLING ADDRESS <br /> BUSINESS NAME � WW'\' 200_ �,iOy- PH¢ALEE#_ ,2!� l�� EXT. <br /> HOME or MAILING ADDRESS V y ice" - 5aY FAX# !�`r <br /> v� ica�a <br /> CITY STATEC M ZIP <br /> BILLING ACKNOWLEDGEMEN : 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 /> L.APPLICANT'S SIGNATURE: DATO� 1 Z{ <br /> PROPERTY/BUSINESS OWNEf -- 6P4ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICaNT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> A� rz2021 <br /> SAN JOAQtI1N C <br /> VIROpM�NtAL N <br /> ACCEPTED BY: (,6rl/L- EMPLOYEE M DATE: /4 <br /> ASSIGNED TO: y- EMPLOYEE#: DATE; 2 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Arnount<A Amount Paid Payment Date 2 z� <br /> Payment Type Invoice# } 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/97/2003 <br />