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SAN JOAQUI- 7OUNTY ENVIRONMENTAL HEAL" DEPARTMENT <br /> .. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O ,3 6 <br /> OWNER/OPERATOR I�41t <br /> CHECK if BILLING ADDRESS El <br /> FACIuTY NAME <br /> SITEADDRESS <br /> SVeet Number Direction , -` Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE g ZIP <br /> PHONE#t) 1 Exr. APN# LAN�U E� CATION / <br /> 40 <br /> PHONE#2 Ext. BOS DISTRICT ('/t(//t LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> S1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Exr' <br /> , till <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 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, ATE and FLLDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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. P AVNAEN-T <br /> TYPE OF SERVICE REQUESTED: ;OctRECEI <br /> COMMENTS: ^11 r la <br /> 0 <br /> S71A EVtJ.tl]VIRONMEN AL" <br /> HEALV1 &PAFiTMENT <br /> ACCEPTED BY: EMPLOYEE#: �Q"l/ DATE: O 57 <br /> ASSIGNEDTO: EMPLOYEE#: Gv// DATE: <br /> Date Service Completed (if a early completed): SERVICE CODE: PIE: 4V4P <br /> Fee Amount: Amount Paid Payment Date <br /> Check# Received By: <br /> Payment Type Invoice# <br />