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<br />SERVICE REQUEST#Type of Business or Property <br />FAciun Name <br />Street Number <br />StateCity <br />Land Use Application #Ext.APNt <br />Location CodeExt.BOS District <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />) <br />ZipStatiCity <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Date:Employee #:Accepted By: <br />Date:Employee#:Assigned to: <br />P/E:Service Code:Date Service Completed (if already completed): <br />Payment DateAmount PaidFee Amount: <br />Received By:Check #Invoice #Payment Type <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />Site Address <br />Street Number <br />Home or Mailing Address (If Different from Site Address) <br />______CityDirection <br />Owner / Operator <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />Street Name <br />Zip <br />Phone #1 <br />Phone #2 <br />( )___________________ <br />Check if Billing Address D <br />Check if Bilung Address O <br />Street Name <br />Date:. <br />Property/Business OwneriEI— Operator/Manager El Other Authorized Agent O <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 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 />Phone# <br />(^1) <br />Fax# <br />( <br />Requestor^—>. <br />____________X <br />Business Name <br />Zip Crxfe 7* <br />-a- C Q'S'&e <0^ <br />Home or Mailing ADDRESS > <br />_______________ <br />_ , — ■'■II ■ <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, STATELand Federal laws.