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SAN JOAQUIN..COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5,4�00S S X546(1 <br /> OWNER/OPERA.R <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME , <br /> SITE ADDRESS FJ Pirecti.. <br /> ,c;cseft Number ` Stfeet Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE#1 /} EXT. APN# LAND USE APP ICATIIONN## <br /> PHONE#2 EXT BOS DISTRICT _ LOCAOTIOt ,QDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILIN(;ADDRESS FAX# <br /> ( } <br /> CITY STATE ZIP <br /> I <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 appli anon"t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA a E , L laws. <br /> APPLICANT'.' SIGNATLTRE: DAXd <br /> ��J� CD <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGEN <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh is requir 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> -K20 <br /> 7 R �3 0 ,� <br /> �) � ��' OUYr1 G� N0 <br /> �pP NME E <br /> ACCEPT Y: EMPLOYEE#: 5 � DATE: <br /> ASSIGNED EMPLOYEE#:� � DATE:.-a/_��� <br /> Date Service Completed (if already completed): SERVICE CODE: �a� PIE:1��Cl/ <br /> Fee Amount: �� Amount Paid CIO Payment Date 31311 o <br /> Payment Type Invoice# Check Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />