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9AN JOAQSCOUNTY ENVIRONMENTAL HEALTSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS q. <br /> Street Number Direction Stre.(IN CI ZI Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) / T-Ck <br /> C t <br /> / Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#; ExT• APN# I LAND USE APPLICATION# <br /> ( 110'1-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> i <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 applic do an e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST d DERAL aws. <br /> APPLICANT'S SIGNATURE: , -- DATE: c> 1 <br /> PROPERTY/BUSINESS OWNER CI PE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 <br /> ��assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thAkA time it is <br /> provided to me or my representative. ""����,/►�,•'s <br /> Alk— <br /> TYPE OF SERVICE REQUESTED: ("? L,-Z- 14 ! 4 <br /> (17 <br /> COMMENTS: yFq NJQ�Q �N 013 <br /> <Ty����tiO N�- <br /> FNr <br /> ACCEPTED BY: --------- EMPLOYEE#: 0 7S7 3 DATE: i Z <br /> ASSIGNED T l EMPLOYEE#: Z (e Z v DATE: 1 —7I z <br /> Date Service pl ed (if already completed): SERVICE CODE: �j6 i P I E: <br /> Fee Amount: Amount Paid 2,�S-p 0 C r Payment Date <br /> Payment Type Invoice# Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />