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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typef siness or Pr e FACILITY ID# SERVICE REQUEST# <br /> FA- <br /> OWNER 000� 3 s z <br /> PERATOR <br /> Y CHECK If BILLING ADDRESS <br /> FACILITY NAME ! <br /> SITE ADDRESS <br /> - Street L city ZIo Code <br /> HOME or MAILING A ESS ( ifferent from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE# T• APN# LAND USE APPLICATION# <br /> 33 a� 2 <br /> PHONE#2 EkT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E' <br /> c -6,15 7 <br /> HOME Or MAILING ADDRESS FAx# <br /> 4 - 5((1 <br /> CITY / STATE ZIP <br /> BILLING AC DGEMENT: 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 app iii'EIEIEI ation and that the work to be performed will be done in ac r ce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I / DATE; Cw 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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: :A: ED <br /> COMMENTS: <br /> JAN 0 9 2001 <br /> SAtENVRONME OAO TM <br /> F1EN-TH DEPAR <br /> FNT <br /> ACCEPTED BY EMPLOYEEM DATE: <br /> ASSIGNED TO: EMPLOYEE#: 'a l DATE: <br /> Date Service Completed (if already mpleted): SERVICE CODE: PIE: 23zj� <br /> Fee Amount: a Amount Paid _ Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />