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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICEp�$�3REQUEST # <br />FAX# <br />( 1 <br />CITY STATE ZIP <br />S� <br />R <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />V <br />SITE ADORES 30 <br />O��Street <br />t vvt <br />Street Number Direction <br />Name�C� <br />I Co <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />STATE ZIP <br />PHONE#1 Enc <br />APN# <br />LAND USE APPLICATION # <br />(2.b) 2�3d — q2 <br />PHONE#2 Ex . <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� <br />CHECK If BILLING AGGRESS <br />BUSINESS NAME <br />PHONE # Ev. <br />HOME Or MAILING ADDRESS <br />FAX# <br />( 1 <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 app ' tie anc t tat the wo be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, AT d F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE t <br />PROPERTY/ BUSINESS OWNE OPERATOR / MANA ❑ OTHER AUTHORIZED AGENT ❑ <br />y APPLlCAN7'is not the BILLING PARTY pros authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of Ute property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmewll/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and d� a it is <br />provided to me or my representative. RE �T <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: e` Q 3 <br />tY O,Eq �]C*m <br />ACCEPTED BY: EMPLOYEE #: Z DATE: 2,C_' V '- <br />ASSIGNED TO: 1,S4 44 EMPLOYEE#: DATE: 'L3 <br />Date Service Compl ed (if already completell): SERVICE ODE: P/: : <br />Fee Amount: Amount P �t)o Payment Date <br />Payment Type _ linvoice# I Check # I Receiv d By: , <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />