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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST i <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP TOR <br /> UA- Ca-aLCHECK If BILLING ADDRESS <br /> r <br /> FACILITY NAME , <br /> SITE ADDRESS f ►p(tel /_ LD J. q� b <br /> treet Number V Dirrection "u— Street am� Ci Zi e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY /J STATE ZIP <br /> T`^ 1/ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> K <br /> BUSINESS NAME PHONE# EXT. <br /> 8 <br /> HOME or MAILING ADDRESS FAX# <br /> / 7 3 ( ) <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applK ah n and that Pe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST TE a EDE laws. Q} <br /> APPLICANT'S SIGNATURE: DATE: !4-21 f <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MAN ER ❑ OTHER AUTHORIZED AGENT 6--w f <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is requir 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: V 5% U <br /> COMMENTS: t n '-L �r� E <br /> T� t�D <br /> l h S O (/� <br /> 64U 21 204 <br /> N <br /> S �� u1COk <br /> M NT EtSf <br /> ACCEPTED BY: EMPLOYEE#: 7' , DATE: V,P <br /> ASSIGNED TO: 1 EMPLOYEE#: C - DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: P, <br /> E: <br /> Fee Amount: Amount Paid .�.Z1 V Payment Date <br /> Payment Type Invoice# Check# �ZS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />