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SAN JOAQUL, ._''OUNTY ENVIRONMENTAL HEALTH ,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n`1 <br /> OW PE R Z O <br /> CHECK If BILLING ADDRESS <br /> ITEEAAD_DRESS "e <br /> Street Number Direction I tteB1111e I ev <br /> HO 0 AILING ADD/PASS (if Diffe ent fro\m Site Address) �Ir}�l/�^` <br /> ` J Street Number St' rest Name <br /> CITY S T <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> "N # ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM u, PIM 6xT.- <br /> M r M ING ADE?S IV FAX# <br /> CITY STAT zip C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent o 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,Standar TATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: a DATE: <br /> . ah vz� <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAN is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the propet'�A; <br /> AAocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment l lent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t �I <br /> provided to me or my representative. <br /> At- <br /> \1ri1_ f- <br /> TYPE OF SERVICE REQUESTED: T V�1�`(( 11/kS e(X�tS1/- S+ 1 <br /> COMMENTS: N FNVIRCUINC <br /> �Ty�FpgR�1N7Y <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I\/ EMPLOYEE#: (./r �y DATE: <br /> Date Service Completed I(if already completed): SERVICE CODE: P I E: <br /> Fee Amount: -I+ Z_ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />