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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property � jJ <br /> OWNER/ OPERATOR 3& CHECK if BILLINADDRESS❑ <br /> FACILITY NAME b <br /> l i" <br /> SITE ADDRESS < <br /> Ar-)L/k r—'Q <br /> V `j/ <br /> Street Number erection <br /> Street Name �� Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ��n/C� CHECK If BILLING ADDRESSO <br /> ✓i l �i t�}1,`�t� EXT. <br /> BUSINESS NAME , _ PHONE# Z <br /> HOME or MAILING ADDRESS FAX# <br /> (') <br /> CITY STATE ZIP <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 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 e ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE FEDE S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> t �' -Z- V� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 4Ct Cy(L.� << t ����r w <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: <br /> COMMENTS: 0�6 <br /> SAN JOA.QUIh'COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �-/ <br /> DATE:,i�� EMPLOYEE#: ? / DATE: <br /> ASSIGNED TO: L <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid fa; l'! i` Payment Date 3 O.. <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />