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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPE TOR f1j <br /> C � /� � CHECK If BILLING ADDRESS■� <br /> FACILITY NAME y�j / <br /> SITE ADDRESS ��� <br /> lJ1n7 Street Number Direction /y Street Name Y Cit Zi Codee <br /> HOME or MAILING ADD S I Different Address) <br /> Street Number Street Name <br /> CITY �p C STA E Z���� <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION(# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMET\ 1 \ \ �,n^ lJ• PHONE# EXT <br /> HOME or MAILING ADDREaS FAX# <br /> 1� ' V6.%t,i/✓I��i /{.fid � (i'L- � ) <br /> CITY i ���_� STAT ZIP L <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 <br /> or 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,STATE enRAws. <br /> APPLICANT'S SIGNATURE: Id DATE: MI <br /> PROPERTY/BUSINESS OWNER OPERATOR/ <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 <br /> COMMENTS: cc)y, <br /> DEC t u � <br /> 6AN ?019 <br /> El VIROHM CouN>1, <br /> EALTH ENT <br /> ACCEPTED BY:L� �� �(� EMPLOYEE#: DATE: <br /> ASSIGNED TO:\J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODEC P I E: \(_p 2 <br /> Fee Amount: �a Amount Paid `�. Payment Date a Q <br /> Payment Type e Invoice# Check# Received By: <br /> 025 SR FORM(Golden Rod) <br /> REVISED <br /> 11/17/2003 <br />