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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> at SERVICE REQUEST <br /> Type of Business or Property Ilium <br /> FACILITY ID# SERVICE REQUEST# <br /> �•�- DC�D rZ 5 � � <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILRY NAME <br /> SITE ADDRESS <br /> Str et Number Direction Stree Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^n <br /> V—U�. V t��� S t,/*1-m CHECK if BILLING ADDRESS I� <br /> BUSINESS NAME J S -Nz P 7�l S G PHONE# EXT. <br /> Slo Ct <br /> HOME or MAILING ADDRESS FAX# <br /> CITY t^ D t ONT STATE /� ZIP <br /> r r— <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: t O '11 o.6 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. 17 <br /> TYPE OF SERVICE REQUESTED: v fJ 1 . <br /> COMMENTS: /1 /fRECEIVE D <br /> OCT 2 7 200,;. <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED By- <br /> EMPLOYEE#: DATE: 7 v <br /> ASSIGNED TO: /j 1 �f EMPLOYEE M U DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O� P i E: <br /> Fee Amount: �"� Amount Paid �� Payment Date �O/,-L-7/O t,, <br /> Payment Type Invoice# Check# g 7 4 Received By: <br /> EHD 48-02-025 SR F `M I en`Rod) <br /> REVISED 11/17/2003 <br />