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SAN JOAQU OUNTY ENVIRONMENTAL HEALTIIWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /� CHECK if BILLING ADDRESS❑ <br /> k(,,V b Q <br /> FACILITY NAME <br /> Owe tk''U Is Cl 0'-')_ X01— <br /> SITE ADDRESS j C-h` '�� <br /> reef umber Direction Street ame Cit 2i Code <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 (� p• 7� T CHECK if BILLING ADDRESS <br /> IBJ E •Y%'�� r1. ����=� � ��/! �✓� .� <br /> PHO EXT. <br /> BUSINESS NAME ��, � �,.�� � � -jet � � <br /> '1 u <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE CA ZIP Cl- <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TE an4 FEDERAL laws, <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ 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 environinental/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: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003x ' gam,_ <br />