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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />S r.W"I <br />w <br />OWNER I OPERATOR <br />C�� O � <br />C✓12 CHECK If BILLING ADDRESS <br />FACILITY NAME 461 <br />SITE ADDRESS <br />U� <br />CALL(209)9S3-7697 <br />FOR INSPECTION.EN <br />Street Number <br />Direction <br />24-HOUR NOTICE <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />DATE: , <br />ASSIGNED TO: F <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />SERVICE CODE: <br />Q <br />PHONE #1 EXT• <br />APN # <br />Fee Amount: <br />LAND USE APPLICATION # <br />ep) 25 - F 1 d Z <br />ZZ <br />--J I <br />Invoice # <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( I <br />- C <br />CONTRACTOR / SERVICE REQUESTOR It 1 <br />REQUESTOR <br />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: 1, 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: At/! ek O DAT�WTitle <br />OPROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER THER AUTHORIZED AGENTIfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 />TYPE OF SERVICE REQUESTED: <br />� p E�/fa <br />�uV <br />COMMENTS: J <br />V <br />wz: <br />U� <br />CALL(209)9S3-7697 <br />FOR INSPECTION.EN <br />SAN <br />OAQQUIN CDU <br />24-HOUR NOTICE <br />HEALTH MEN <br />MENT,gf <br />ACCEPTED BY: � <br />/ <br />REQUIRED. <br />EMPLOYEE #: <br />DATE: , <br />ASSIGNED TO: F <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />O,� <br />P I E: <br />Fee Amount: <br />Amount Paid -- <br />Payment Date <br />ZZ <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />