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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITx 11D# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> 'Sl <br /> FAry NAME S` u <br /> SITE ADDRESS r_ <br /> Y Street Elu r Direction `v !Vtree Name <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Stleal <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# / LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> (� ) g001 s s- ov 5 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> �! ��►� CHECK if BILLING ADD Es <br /> BUSINESS NAME PHONE# Ext. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CIN 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 or <br /> 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 ERAL la <br /> APPLICANT'S SIGNATUR DATE: -7 <br /> PROPERTY/BU51NESS OWNER❑ OPERATOR/MANAGER/ffOTHERAUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at thbove <br /> site address,hereby authorize the release of any and all results,geotechnical data andlor environmentaVsite assessment infI <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the sante time it is providA <br /> my representative, <br /> TYPE OF SERVICE REQUESTER: r ( �® <br /> COMMENTS: <br /> N 'yo NMF18 <br /> CO <br /> �y�J 2 T <br /> ACCEPTED BY: EMPLOYEEM �! I J DATE: <br /> ASSIGNED TO: � EMPLOYEE#: �/� /„ DATE: p <br /> Date Service Completed (if already completed): SERVICE CODE: +©0 Pit: O 3 <br /> Fee Amount: Amount Paid CO Payment Date S <br /> Payment Type lnvolce# Gheck# ;2��3 Re6146d By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 0767(08 <br />