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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />MAY 052016 <br />Type%f Business or Property <br />C..✓ <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/E <br />TO <br />CHECK if BILLING ADDRESS <br />FACILITY NAME�s— <br />FAX# <br />CITY C& <br />SITE ADDRESS <br />Street Number <br />�pj� j/( <br />D rl action <br />t e <br />SERVICE CODE: <br />C <br />1 de <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Payment Date <br />UtName___ <br />CITY `' I STAT <br />ZIP 2� <br />J <br />Received By: <br />PE#1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 .� r 1 4 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />• •R / SERVICE REQUESTOR <br />REQUESTOR "' <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME Or MAILING ADDRESS %� �/� ' <br />FAX# <br />CITY C& <br />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 <br />or activity will be billed to me or my bus` ss as ide_ tiiied' on this form: <br />I also certify that I have prepared th' applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand ds, TAT and FED <br />APPLICANT'S SIGNATURE: DATE: C37 <br />` t <br />PROPERTY/BUSINESS OWNER❑ ERAT 'TANAGER ❑ 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 available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />G jNTS' <br />1 0 <br />ACCEPTED BY: p ` PL E <br />ASSIGNED TO: EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />W <br />SR FORM (Golden Rod) . <br />0N <br />