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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of B,6siness or Property <br />FACILITY ID # <br />PHONE# EXT. <br />SERVICE REQUEST # <br />S �Q 00S�I-3 l <br />OWNER / OPERATOR <br />-�_e lie n <br />�T <br />�j <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITEADDRESS <br />Street Number <br />Direction <br />` <br />/ Street Name <br />�� co�0�� <br />S.� o� _Ae71 <br />Cit <br />20� z� <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATIONODEy <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />"l• 0 V y / CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <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 />1 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 TE and FED L laws. <br />APPLICANT'S SIGNATURE DATE:Z- <br />PROPERTY / USINESS OWNER O ,BATOR /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, 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 sar]le time it is <br />provided to me or my representative. I7 <br />TYPE OF SERVICE REQUESTED: (, <br />COMMENTS: <br />> <br />ti�FTyo <br />�� co�0�� <br />FA,gRFT T,�N�y <br />ACCEPTED BY: <br />EMPLOYEE #: , <br />DATE: �O Z <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: l <br />Amount Pai <br />/S -; <br />Payment Date <br />l��y <br />Payment Type <br />'S� <br />Invoice # <br />Check # /3 3$3� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />>S <br />A <br />9 <br />