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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />lb SERVICE REQUEST 0 <br />Type of B iness or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />1 <br />PHONE# <br />t `4 <br />HOME Or MAILING ADDRESS ,[/� <br />/ <br />OWNER OPERATOR . <br />��7 ) <br />CHECK if BILLING ADDRESS❑ <br />rn <br />ASSIGNED TO: <br />EMPLOYEE#: - <br />DATE:. <br />Date Service Completed (if already completed): <br />FAcIUTY NAME <br />PIE:/ <br />Fee Amcunt: CS> <br />$ITE ADDRESSr-6zet /Voin,�.( <br />J' Nu%ber Direct/io.�nl(.r/L/ <br />Slreel Name <br />C.de <br />HOME or MAILING ADDRESS ( Different from Site Address <br />Payment Type <br />invoice # <br />Check # d ` S <br />Received By: G� <br />Street Number <br />Street Name <br />CIN <br />STATE <br />ZIP <br />PHONE #1 EXT. APN# <br />LAND USEAPPLICATION# <br />' / <br />BOS DISTRICT <br />/ <br />LOCATION CODE <br />PHONE #2 ExT' <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST OR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PHONE# <br />t `4 <br />HOME Or MAILING ADDRESS ,[/� <br />/ <br />ACCEPTED Y: �/J <br />��7 ) <br />CITY <br />STATE ZIP 95aar <br />BILLING ACKNOWLEDGFMFNT: 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: 6m: DATE:O <br />PROPERTY/ BusrNESs OWNER❑ OPERATOR/ MANAGER ❑ OTHERAuTHORIZEDAGENT-1,/ � <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 environmentallsite 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 />rovided to me or my representative. <br />P <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED Y: �/J <br />EMPLOYE E#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: - <br />DATE:. <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE:/ <br />Fee Amcunt: CS> <br />Amount Paid <br />`a 9 , <br />Payment Date <br />Payment Type <br />invoice # <br />Check # d ` S <br />Received By: G� <br />EHD 48-02-025 a�?"o"') <br />REVISED 11/17/2003 <br />