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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> T e of Busines o P operty FACILITY ID# SERVICE REQUEST# <br /> OOJER/OPERATOR <br /> Cj CHECK If BILLING ADDRESS <br /> FACILITY NAME �\ <br /> SITE ADD E[$$ (� �/y <br /> 7 Street Number Direction �n� Str�me Cit �ode� <br /> HOME Or MAILING ADDRESS (If Different from Sit Address) <br /> Street Number j� �a' Street NaFne "'p <br /> CITY $TATE I <br /> GCJ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHQ�#j �� EXT. BOS DISTRICT LOCATION CODE <br /> /[WKj CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHON <br /> HOME Or MAILING ADDRESS _ FAX# <br /> CITY � $ 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STtE and FEDERAL law ,( / <br /> APPLICANT'S SIGNATURE: / �/ �/CJ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT-9- <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. PAYMEN I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: CjEf L+ <br /> LUU <br /> SAN JOAQUIN COUNT`! <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 04& '7 DATE: C _Z� <br /> S / --� � <br /> ASSIGNED TO: EMPLOYEE#: Q' DATE: <br /> Date Service Completed (i alrea completed): SERVICE CODE: P/E: <br /> Fee Amount: 1, Amount Paid -%�"7 ! 0 Lj Payment Date v <br /> Payment Type �`-tom_�� Invoice# Check# h vel Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />