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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT' T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of usiness or Property FACILITY ID# ERV E REQUEST# <br /> -` <br /> -k1 ' <br /> OWNER/OPERATO <br /> i CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ' <br /> SIT� RES Lot Number � ��� <br /> Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site A ss) <br /> Street Numb Street Name <br /> CITY STATE ZIP <br /> PHONE#1 XT APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME P qw- <br /> HOME or MAILING ADDRESS F <br /> g)j) t 1 (1 � <br /> CITY n ° 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 FEDE laws. <br /> c 11 C <br /> APPLICANT'S SIGNATURE—Q1) �A DATE: `�l `� <br /> PROPERTY/BUSINESS OWNER El OPERATOR/Nf NAGER ❑ OTHER AUTHORIZED AGENT❑ \1t� _ MJ K <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 /> C— V 10 <br /> 1N C�vNN <br /> SAN SOF ONME.SENT <br /> EN`.�pEPPR <br /> ACCEPTE BY: -.,-- O EMPLOYEE#: <br /> ASSIGNED TO: / EMPLOYEE#: j /, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: q7 <br /> Fee Amount: ���U� Amount Paid 1�3 L(o. O 0 Payment Date l ( <br /> Payment Type ' Invoice# Check# 0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />