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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (0o z n S o <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME `^ (� <br /> SITE ADDRESS <br /> CStreet Number Direction Street Name v Cit Zi CodeV <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#T EXT. BOS DISTRICT LOCATION COBE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <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 <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,STATE and FPFDERAL l6s. <br /> APPLICANT'S SIGNATURE' DATE: '1 7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER .. HORIZED 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 /> COMMENTS: RECEIVED <br /> OCT 17 2012 <br /> Sur JOAQUIN COU9 Y <br /> EWRONMENTAL <br /> HF,AJ_TH®€ fiME4ff <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): t� SERVICE CODE: S -L— <br /> Fee Amount: v,. &A Amount Paid Payment Date -Z <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />