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SAN JOAQUI UNTY ENVIRONMENTAL HEALTBOPARTMENT <br />Type f usiness P operty <br />Ablw MOAJ <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNE / OPERATOR <br />. • <br />CHECK If BILLING ADDRESS <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />FAcicmr NAME <br />P i E: <br />Fee Amount: <br />SITE ADDRESS <br />5wumber <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />WfL+efion <br />HOME of MAILING ADDRES (If ifferent from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />Qc) 3+-333 <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATIO N CODE <br />( `- <br />/ . \ ► mac% ► ► ►@ 0_ _ <br />• s •/010Ft �/IIJ�I ��� r <br />• •� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />. • <br />-ASSIGNED TO: - <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <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 or <br />activity will be billed to me or my bnsi as identified on this form <br />I also certify that I have prepared th' ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes Standar s ATE and FEDERAL ja <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLINGPARTY, proof of authorization to sign is reguil 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 />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />-ASSIGNED TO: - <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />IR" Olv i t ids r $Rod} <br />REVISED 11/17/2003 <br />