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SAN JOAQUINUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o S\(-\,D N �Z6e7 <br /> OWNER ERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 3 Street Number Street Name CI` <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 /> Q090 -1 Ll-1 - C[-I D---1G�( SOU <br /> PHONE V EXT. BOS DISTRICT LOCATION CODE <br /> (aol) 1 -1 '-1 -1 ©0 0-2- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS21 <br /> BUSINESS NAME C \\ J PHONE# EXT. <br /> ac�(� 209 v <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY Gcooc 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, S and FEDERAL laws C <br /> APPLICANT'S SIGNATURE: CDATE: <br /> PROPERTY/BUSINESS OWNER OPERA R NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is of 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: j� <br /> COMMENTS: — ` U�' ilk <br /> CD <br /> �Evr <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: C \EMCV-N EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: (Ar 1 P I E: �8f3 <br /> Fee Amount: U Amount Pa' a �.bU Payment Date <br /> Payment Type invoice# C ck# �a9�oto Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />