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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Ousiness or Pr a FACILITY ID# SERVICE REQUEST# <br /> vo b Zia .65V_00 qq3&6 <br /> OWNEOPERATOR C �} <br /> ,' /'/ ' CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS _ <br /> Street U er DirectionNet Name Zi Code <br /> HOME or MAILING ADDRESS (if Different from Sit Address) <br /> Street Number Street Name <br /> CITY L/d STATE ZIP <br /> PHONE#1EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 od O1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NA PHONE# EXT. <br /> 3 <br /> HOME or MAILING A16DRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNONVLED NT: 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 a lic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TAT and FEDERAL 1 ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> U 1� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN <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. w '; <br /> TYPE OF SERVICE REQUESTED: S� �ECEw <br /> COMMENTS: <br /> AQU1N COUNT <br /> H�TN DEPARTM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ( // <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> c3plUeteif already completed): ER <br /> RVICE CODE: PEDate Service Co l 2-369 <br /> Payment DateFee Amount: Amount Paid <br /> Payment Type Invoice# Check# ` Received By: ;v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 eo F <br />