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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/OPERATOR <br /> 05 P <br /> /,y=C E51 ILLING ADDRESS <br /> FACILITYNAME \� `�1C. (� <br /> n <br /> SITE ADDRESS 7Q C <br /> —" Street Number Dl ion -W1 Name `-' / ✓ Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> c2. _ <br /> - � Street Number Street Name <br /> CITYI _ _ STATE ZIP <br /> C <br /> PHONE#1 Ex. APN# LANb USE APPLICATION# <br /> !:.) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> t 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C:7 r- t _ few CHECK If BILLING ADORE <br /> . , l 'Sc <br /> BUSINESS NAME PHO E# En' <br /> HOME Or MAILING ADDRESS t— r�` FAX# <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:t :y�/ � � use I ✓ — � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> Ir 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 same time it is <br /> provided to me or my representative.. p� <br /> TYPE OF SERVICE REQUESTED: 1n t� hl <br /> COMMENTS: � �V�D <br /> It 0 1� <br /> j JOAQUUV C 22 <br /> H TM p gst v�tIV <br /> ACCEPTED BY: '''���ttt EMPLOYEE#: DATE: T <br /> ASSIGNED TO: ' I� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: !�� <br /> Fee Amount: i S� Amount P d v Payment Date 2 Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />