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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prpperty FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I <br /> 1 t u er Direction Street Name P'W Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REQUESTOR , �t <br /> Q Min <br /> CHECK If BILLING ADDRESS <br /> ✓ 111 �\\777111....��� \ <br /> BUSINESS NAME ; P N <br /> H M NG D ESS L'' (I • . ,t ► , ,1 FA%# C C r <br /> w N \V{vy ) <br /> CITY STATE ZI R4 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,952n 53 ``1 <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project 0I� <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 JOAQUINCOUNTY Ordinance Codes,Stan STATE and FEDERAL laws. CIQ <br /> APPLICANT'S SIGNATURE. Fllw, O DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT 11 <br /> If APPLicANT is not the BLLLING 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 environmentaVsite 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. PAYMENJ <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: <br /> APR 0 7 2 <br /> SAN JOAOUINNfAL t <br /> IRONP E�NTQAcyLr,I-T- <br /> ACCEPTED BY: EMPLOYEE#: �3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 PIE: ¢�Z <br /> Fee Amount: 04, Amount Paid `8'�, D-D Payment Date ��-7 <br /> Payment Type �- Invoice# Check# a, /S T Z_ Received By: <br /> EHD 48-02-025 SR FORM(GoldenRod)REVISED 11/17/2003 <br />