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SAN JOAQUIN,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of sines or Pro erty FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> CHECK if BILLING ADDRESS❑ <br /> a/ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction (� Street Name Ci Zip Code <br /> NOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number F Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• LAND USE APPLICATION# <br /> APN# <br /> ill leas L 5 s�'0 (uS�- 0 4(D --i L- <br /> PHONE#2 EXT. B OS DISTRICT LOCAnON CODE <br /> c l 1 (f <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTORL/C <br /> CHECK It BILLING ADDRESS❑ <br /> BUSINESS NAME _ PHONE# EXT. <br /> ;;z cl&r_ &33 <br /> HOME or MAILING APRESS FAX# -/& <br /> STATE Zip <br /> BILLING ACKNONVLEDGEMENT: 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, TATE and FEDERAL laws. �p 1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AvTHORIZED AGENT❑ <br /> If AmiCANT 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. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JUIV 0 1 20 <br /> 0 <br /> 7SaIVJQAvRQU1ht C UH�xH ONME T N7y <br /> OEp nAL <br /> emr <br /> ACCEPTED BY: L L VE i EMPLOYEE#: 3 2 j DATE: aP` !f 7 <br /> ASSIGNED TO: yi r F i—Lt C EMPLOYEE#: C3 j 7 DATE: � t( <br /> Date Service Completed (if already completed): SERVICE CODE: t�� Pit E: � 3 <br /> Fee Amount: ,r _ 0)_ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 $IR F(}RM(Golden Ftod} <br /> REVISED 11/1712003 <br />