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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ayOWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Md ;.AJ Ci A�JOeA Zip Code 7 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <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 /> BUSINESS NAME PHONE# e^� ExT. <br /> 7 — 7 S / 3 <br /> HOME Or MAILING ADDRESS FAx# G <br /> O <br /> CITY .S toe k 4 o,v 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: S'— <br /> PROPERTY <br /> j—PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ 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 availlaahle. �same time it is <br /> provided to me or my representative. HAS{ <br /> TYPE OF SERVICE REQUESTED: (/IST �L�/I-R tr F ) O? <br /> COMMENTS: <br /> GOUN� <br /> SA�NVIR NMER N►Et� <br /> N�SN pEPA <br /> ACCEPTED BY: EMPLOYEE#: C)-)S ?j DATE: S �'0-0-7 <br /> ASSIGNED TO: A/1 t0q` If)" EMPLOYEE#: ,(p'?Q DATE: S 71D,— <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 23v't <br /> Fee Amount: 2q'S .av Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ` ,SIS 1 QRM.(to'lifen`Rod) <br /> REVISED 11/17/2003 <br />