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0A1-4 J VAtl U 11V L,V Ui-4 l Y E 1N V InkJ01V1r,1N 1 AL KIEAL t 111JhJrA K 1 1V1r 1V 1 <br /> SERVICE REQUEST <br /> Type of Busine r Property FACILITY ID# SERVICE REQUEST# <br /> boa <br /> OWNER/OPE If <br /> OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> W U <br /> SITE ADDRESS Viad4Cet <br /> 6 <br /> Street Number Direction it 4 Zip Coder <br /> HOME Or MAILING ADDRES If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (Z7 ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CO TRACTOR/ SERVICE REQUESTOR <br /> REQUE R <br /> CHECK if BILLING ADDRESS <br /> BUSIN AME !•� PHONE# _ EXT. <br /> HOME or MAILING RESSFAx# <br /> A- �) -63�2 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLE 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 ap I tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTatlu tl mfi <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: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ' ,SR 1 QRM(Golden food)' <br /> REVISED 11/17/2003 <br />