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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />o hb <br />SERVICE REQUEST # <br />OWNER/ OPERATOR �^ <br />/, %n <br />CHECK if <br />FACILITY NAME <br />BUSINESS NAME <br />SITE ADDRESS <br />street Number Direction <br />a --1 <br />Street Name <br />EXr. <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�/ <br />CHECKifBILLING ADDRES <br />t L'I ✓r / CC �� <br />RECEIVED <br />SEP 2 8 2012 <br />IIAN JOAQUIN COLHIiY <br />ENVIRONMENTAL <br />HFJILTH DEPARTYENr <br />BUSINESS NAME <br />PHONE # <br />EXr. <br />HOME Or MAILING ADDRESS � � � <br />FAX # <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />CITY c,10$TATE <br />�+� <br />ZIP �-:-- T�r <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 <br />or 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 wo .k to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL 1 S. <br />APPLICANT'S SIGNATURE: DATE:/ <br />PROPERTY/ BUSINESS OWNER❑ OPERA NAGER [3 OTHER AUTHORIZED AGENT �Y G X 4.1 <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: <br />P/eY M E N T <br />COMMENTS: <br />RECEIVED <br />SEP 2 8 2012 <br />IIAN JOAQUIN COLHIiY <br />ENVIRONMENTAL <br />HFJILTH DEPARTYENr <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: d <br />Fee Amount: i <br />Amount Paid2� 00 <br />Paymb <br />I <br />t Date <br />7/ <br />Payment Type <br />Invoice # <br />I Check # D <br />Rece ed y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />