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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 /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> C v Street Number Direction 3trc�et IGz �7t/ Zip Cod <br /> HOME or MAILING ADDRESS (If Differenttt from Site Address) _ <br /> Street Number Street e <br /> CITY / / STATE ZIP <br /> PHONE#1 EXT. APN# O / LAND USE APPLICATION# <br /> Rfif <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A / <br /> `� /v� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 321, <br /> CITY , c kS ATE gig <br /> ¢� <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,ST EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �`''L y/ /7 Zy 2Z <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/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 AW d at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si e <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the RftMVIED <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N L- S NUV T7-2-(22 <br /> COMMENTS: f;eVie� SAN JOAQUIN CO JNTY <br /> ENVIRONMENT <br /> HEALTH DEPARTh IENT <br /> ACCEPTED BY: EMPLOYEE#: �lJ %� DATE: Yl /7 22 <br /> ASSIGNED TO: /Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: JG Zj3 P 1 E: Zip O-Z— <br /> Fee <br /> Fee Amount: (0 ZLf Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />