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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f-A Sw 002 h► SS <br /> OWNER/OPERATOR �+ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> � (7 <br /> SITE ADDRESS <br /> be Dlrecl o Street Name Clt ZI Code <br /> HOME or MAILING ADDRESS Jif Different from Site Address) <br /> e2III I 1 street Number Street Name <br /> CITY STATEQ 5� ZIP <br /> 7J Com- <br /> PHONE#1 EXT. N# LAND USE APPLICATION# <br /> °`) 4 G AP <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> -'I ,�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME r I / /l C-1 <br /> PHONE# �, Ezi. C-7/ <br /> HOME Or MAILING ADDQI:SS 15 f/A FAX# <br /> I2� I f / tike u1 L—F— ( ) <br /> CITY U�i� yV 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BITSINESS OWNER'13 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ �t +�NLS <br /> If APPLICANT is not the BILLING PARTY,pro f Of attiltoriZation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environm Ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an t *.Ct��t is <br /> provided to me or my representative. Cc ,,`c <br /> TYPE OF SERVICE REQUESTED: Jr fy� Ll' <br /> COMMENTS: S,qy V <br /> 30, <br /> J0'JQ1J/,yET <br /> © <br /> Ty'0FPgRN/Y�H <br /> ACCEPTED BY: enV -- EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / Cl L PIE: O / <br /> Fee Amount: , 'C;Z — Amount Pai /1 D� Payment Date g <br /> Payment Type � Invoice# Check#37 / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />