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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME fil <br /> SITE ADDRESS ' 0 z-,"Al a <br /> Street Number Direction Street Name Ci "/� Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ' / or <br /> Street Number �1 Street Name, <br /> CITY STATE ZIP <br /> 'FCC-1- - r S- 7� <br /> PHONE#') If EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( <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 HEAL-rII DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fon-n. <br /> I also certify that I have prepared this application and that the work to be perfonned 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 /> 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: ( tD - �� `�v1'1/Z: �}✓1 �`"� ������—v <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: / DATE: Lt —10 <br /> �3 <br /> ASSIGNED TO: "A EMPLOYEE#: C �L� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� l P 1 E: tr -7 V0 <br /> Fee Amount: 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 />