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SAN JOAQUI....,--OUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR fCHECK if BILLING ADDRESS❑ar `I� �► � P � 1 <br /> FACILITY NAME <br /> SITE ADDRESS / !`(X / c freet <br /> Name(-m--e — Zi CodeDirection Ci <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ,( CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH E# EXT. <br /> 644 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 applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a FEDE laws. <br /> APPLICANT'S SIGNATURE: tUr DATE: <br /> PROPERTY/BUSINESS OWNER El P TOR/NINAGER El 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 JOAQUfN 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: P S� LA <br /> COMMENTS: <br /> 4 X004 <br /> 112 L ��"!�, /� SAN JOAQUIN COUNTY <br /> \ / ENVIRONMENTAL <br /> LTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: l 1� DATE: <br /> ASSIGNED TO: �/]/� EMPLOYEE#: L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: <br /> Fee Amount: l� F� Amount Paid .I V7 Payment Date <br /> Payment Type Invoice# Check# /�� Received By:2�C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />