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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ko b a ) ;2_0 j <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS u <br /> M <br /> FACILITY NAME ttt <br /> SITE ADDRESS 1. " C r <br /> Street Number Direction / r Street Name ),Nvf Cit Zi 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# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> G (i <br /> CHECK If BILLING ADDRESS <br /> BUSINES NAM <br /> PHONE# EXT. <br /> tµ , ) ir. �� ma �u I I ens ri, <br /> HOME or MAILING�AD1D1RESS FAX# <br /> I' J c / ( ) <br /> CITY STATE ( zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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, ST TE an DERAL laws. q <br /> �/� // <br /> APPLICANT'S SIGNATURE: DATE: � / <br /> PROPERTY/BUSINESS OWNERE3-- 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: lwls— <br /> RECEI <br /> SEP 2 6 201 <br /> SAN JOAQUF:NVIRQIN O AN <br /> ACCEPTED BY: EMPLOYEE#: DATE: HEIALTH,PER RTMENT <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1.17 41,11 <br /> Date Service Completed (if already Completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Paid — Payment Date <br /> Payment Type L Invoice# Cbeek# d�j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />