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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T of Susi es roperly, FACILITY ID# SERVICE REQUEST# <br /> tiVUWV� 1�tIl�.Y111/�(1 O CNECKMBILLING ADDRESS <br /> FACarrrNAM u— <br /> 2-0SrtE�pD$F�58 Su"t Number l� Code <br /> N m C't Zi Code <br /> HOME or MAILING APRESS (If Different from Site Address) <br /> 0—, ~ Street Nembar Stre tN me <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> 2 G c� 03 <br /> PHONE EXT• BOS DISTRICT LOCATION COOE <br /> 23 �t 35 G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> J r7fC-i/ �O'• <br /> HOME Or MAILING ADDRESS FAX# <br /> -Iwipill (✓G• u I Tin S I I i <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 <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 tha he work to be performed will be done in accordance with all S JOAQUIN <br /> COUNTY Ordinance Codes,Standards VkTE and , laws. 1 <br /> APPLICANT'S SIGNAT RE DATE: <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER 13 ER AUTDORIZED AG <br /> IfAPP/aCANT is not th BIL=PARTY.proof of authorization to sign is requ red Title <br /> AUTHORIZATION TO RELEAS 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Ago <br /> ACCEPTED Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: v EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: ?fes P I E: 'L <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />