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SAN JOAQUITtif COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ✓. Y--) CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �G ������/I✓J/1./� ���.y li.,w,.,,1� , ��i[�Z <br /> Street Number Direction Street Name city./� Zip Code <br /> HOME or MAILING ADDRFM <br /> (If <br /> 2�✓J •v Different frSiteA ress)� <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 /> ( ) t / t 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 12 1 <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME �-1 PHONE# ExT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 ass elenntt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same 'tel <br /> provided to me or my representative. C � � <br /> TYPE OF SERVICE REQUESTED: Cb-Ps t�1-H n '94A, `Z46 <br /> COMMENTS: ,r o V\r C� T HFgFN g4UN o�4 <br /> ACCEPTED BY: � ESGb C�1(�aa EMPLOYEE M DATE: <br /> ASSIGNED TO: n �i tZD d EMPLOYEE M DATE: 1-W1 Ii <br /> Date Service Completed (if already completed). SERVICE CODE: oW P/E: LAt u <br /> Fee Amount: Amount Paid �SQ O-D Payment Date <br /> Payment Type Invoice# Check# ecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />