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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busine r Property FACILITY ID# SERVICE REQUEST# <br /> itoj 13 Z4- <br /> OWNER <br /> 4- <br /> OWNER/OP liltm <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction lacQet i 2 Zi Code <br /> HOME Or MAILING ADDRES If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I 7 EXT' APN# LAND USE APPLICATION# <br /> ( 1 > V <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CO TRACTOR/ SERVICE REQUESTOR <br /> REQUE R � <br /> !a /j CHECK if BILLING ADDRESS <br /> U _ <br /> BUSIN AME � � �/� - �� PHONE# ExT. <br /> HOME Or MAILING A#RESS6 <br /> 4 FAX#r--,6e3 �) <br /> CITY n4hAll-�AM-1) <br /> //W`- STATE ZIP �( <br /> BILLING ACKNO`VLE GEMENT: 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 app t tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: / D� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �C <br /> If APPLICANT is not the BimNGPARTY 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: �%S% CcTIL' T ED <br /> COMMENTS: <br /> SAN ENVIRONJOAQUIN COUN]y <br /> MENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ( tri EMPLOYEE#: L�3 2 / DATE: < '7 OS' <br /> ASSIGNED TO: �.4GiC vu EMPLOYEE#: 3 DATE: 4 <br /> Date Service Completed (if already completed): SERVICE CODE: t G� �i P 1 E: <br /> Fee Amount: p� Amount Paid � A, �s; Payment Date <br /> c <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden'Rod) ' <br /> REVISED 11/17/2003 <br />