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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 C- (2- <br /> S l�I <br /> OWNER/OPERATOR y <br /> 1/t j � n ^ CHECK if BILLING ADDRESS E] <br /> FACILITY NAME 1 T f l C+t <br /> SITE ADDRESS <br /> / Street Number Dire"coon Arest m'/eZ- t l� � ZI 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 /> . <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> /// CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTQR � CHECK if BILLING ADDRESS <br /> EXT. <br /> # <br /> BUSINESS NAME � PHONE / <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 jLtlie same time it is <br /> provided to me or my representative. #A <br /> TYPE OF SERVICE REQUESTED: r' ✓(r� *-k'9 liloo-- <br /> COMMENTS: ec <br /> ►Jolt.. ?019 <br /> H �M"tRp��N c0 <br /> �9CtyvF 4 <br /> NT <br /> ACCEPTED BY: A) EMPLOYEE#: L DATE: <br /> ASSIGNED TO: , v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: _523 P I E: Z L� <br /> Fee Amount: �� L Amount Paid L Payment Date l <br /> Payment Type Invoice# Check# ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />