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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o f (s) <br /> NER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction G Str�e�e't/Name Ci ! Zip�C.(e <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 /> c4o 6�)- <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�C' <br /> / � CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# ( EXT. <br /> 2 A: � f`� <br /> HOME r MAILINGADDRESS FAX# <br /> "I/ <br /> - <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 application andjhaf'lhe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and DERAL laws. <br /> APPLICANT'S SIGNAT DATE: 5 vL� ,y <br /> PROPERTY/BUSINESS OWNS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: QFC t�N rY <br /> COMMENTS: W"r /6'�-C 1 ]4—1l` <br /> - t��!I/ <br /> oq 1 2006 <br /> H FNVIRONCO <br /> ERMUN71' <br /> w ?-,76-,1 l -'NFNT <br /> L I �C--) <br /> a QST— l <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: <br /> If <br /> Fee Amount: ���� Amount Paid '1 of n) Payment Date 2 l r, <br /> Payment Type �� Invoice# Check# q913L q913 <br /> Received By: <br /> EHD 48-02-025 ` ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />