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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> SITE ADDRESS 'V N <br /> Street Number Direction StreetteName a� City Zip 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 /> ( ) r'i 10 <br /> PHONE#2 ExT. BOS DISTRICT // LOCATION CODE <br /> ( ) L.l{i <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> U /02- <br /> `Z CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> eq ao <br /> ( ) <br /> CITY STATE ZIP (' J r n <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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> 4,APPLICANT'S SIGNATURE: , DATE:--" ' 6 P— el� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ C"2/),1-//(:, 2 41 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required PAYMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the p ENE!®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,Eiglye"e it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (,��� C� ^� �, ENVIRONMENTAL <br /> COMMENTS: }7 )`� C S /` 6/' <br /> cc L{'J � <br /> �cr o X10 Z) <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7.- P I E: <br /> Fee Amount: Amount Paid v Payment D to 0 �2_ <br /> Payment Type Invoice# Check# Z S 2-- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />