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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 SERVICE REQUEST <br /> Typ usin s or Property FACILITY ID# SERVICE REQUEST# <br /> FA 000 � Roo 45D 73 <br /> OWN / O MkDN1WZV <br /> '1 <br /> Street'�( CHECK If BILLING ADDRESS <br /> FACILITY NAME t * <br /> SITE ADDR / (�Q (r`, R10. <br /> Num3er Olrection Street Name i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number r <br /> CITY 1,,�1 ZIP <br /> #f ^�U' NEXT. 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 / pH E EXT. <br /> HOME or MAILING ADDRESS ^,i l FAX# <br /> CITY STATE <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 applition and that the work to be performed will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDERAL laws. � /�i <br /> APPLICANT'S SIGNATURE: W✓ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN <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 environme�nteall//siiteTassessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablepwAg�G�time it is <br /> provided to me or my representative. RECE(V <br /> TYPE OF SERVICE REQUESTED: ZOOS <br /> COMMENTS: OUIN COUNTY <br /> HEALTH DEPARWE", <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 03 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (Q iE:Z30 <br /> Fee AmounP-7 ©0 Amount Paid /l� Paym t Date \'L S b S <br /> Payment Type Invoice# Check# \p 3 Received By: <br /> rl, [ <br />