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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �2 ©� � Z- <br /> OWNER/OPERATOR <br /> } tt ✓L ( CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS T"" pL�C q Street Number Direction treat Name Cit ZiCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME / PHONE# r EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STAT <br /> �4 zip- <br /> BILLING <br /> IP-BILLING A KNOWLEDGEMENT: 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 1 have prepared this app ' tion and t at the work to be rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT and F ERAL wS <br /> APPLICANT'S SIGNATURE: ` — 6 <br /> DATE: <br /> PROPERTY/BUSINESS OWNER*- OPERATOR/NIANAGER ❑ 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 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:, :Cdt-;,}I fy W P 11S r4 i 3 t't'61,,/1 t7 e i !2 'f-O -s fe ),f, f ll! <br /> COMMENTS: 171J�us� p> 1S Gt } )�C7'y� LC�JYIL 1(/� IY 1 �G�• WIC <br /> REceI� 7, <br /> f d eo <br /> ANY <br /> 0 Z�ZO <br /> M NQUlJV <br /> VIROA COUNTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: S <br /> ,� McNT <br /> ASSIGNED TO: l EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: ,��f ��S P I E: l/d pa <br /> Fee Amount: J S� Amount Paid �"/ IQ. Payment Date 2 o12-4o <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025IO(��/ ZI SR FORM(Golden Rod) <br /> REVISED 11/17/2003 7 <br />