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SAN JOAQUL. —'OUNTY ENVIRONMENTAL HEALTI _ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> c2� .J <br /> FA NAME <br /> G✓A �Gr <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME <br /> gor MAILING ADDRESS (If <br /> Different from Site Address) <br /> I Street Number Street Name <br /> Cl STATE ZIP <br /> 2� , <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) v ( O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ,REQUESTOR <br /> CHECK If BILLING AD ESS <br /> 0 <br /> USI SS NAME PHONE# EXT• -- <br /> ,,HOME or MAILING ADDRESS FAx# <br /> CITY �1'� ��1L� ,� 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 <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 Ordi ce Codes,Standards, ST �nd FEDERAL laws. <br /> APPLI ANT'S SIGNATURE: 2 3 <br /> PROPERTY/BUSINFSS OWNER❑ OPERATOR/MANAGER ❑ OTIIFRAUTHORIZEDAGENT <br /> IfAPPLICANT 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. 1T <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SEP r <br /> SAN JOACJUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: >j Z /3 <br /> ASSIGNED TO: V t n EMPLOYEE#: DATE: l <br /> Date Service Completed (if alread completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date q a3 <br /> Payment Type Invoice# Check# Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />