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b7A1N J0AyU11N k_"UIN 1 Y i'.1N V11{V1N1V1E1N 1'AL I EAE—,111 irLx n=�^••—' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS D <br /> FAC1LrIY NAME <br /> SITE ADDRESS 1 ofI „ 9 � <br /> z cede" <br /> Street Number Direction S t Nam <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street N Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> { 1 Exr BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> ( 1. <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REWUESTORy � HECK if BILLING ADDRES <br /> BUSINESS NAME <br /> }NOME or MAILING ADDRESS Q <br /> l v`y STATE ZIP <br /> CITY GS1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of salve, <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 /> CQUNTY Ordinance Codes,St TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> �gOpERTYI BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTH AUTHORIZED AGENT❑ T rte <br /> IfAPPLICANT is not the BILLINGP.ARTf proof of authorization to sign is required <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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> SERVICE CODE: PIE: <br /> Date Service Completed (if already completed): <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> ,SRS�QRM(Galdep'RSdj <br /> EHD 4.8-02-025 <br /> REVISED 11117/2003 <br />