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r SAN JOAQUINWUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VV-1e," �Aj C V <br /> OWNER/OPERATOR � / <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS � (�/ n, ( �� 1k � L <br /> 1`52C&� <br /> Street Number ir Street Name city Zip Code <br /> HOME or MAILING"2�ADDRESS (If Different from Site Address) DCS �� <br /> — Street Number re Name <br /> CITY ( STATR ZIP <br /> PHONE#1 U ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> '� CHECK If BILLING ADDRESS <br /> BUSINESS NAME - 1 Y I PHONE# EXT. <br /> HOME or MAILING DDRESS J FAX# c <br /> C I t ) <br /> CITY <br /> 1 STATE ��/� ZIP G� <br /> `�04 l� I <br /> BILLING ACKNOWL DGEMENT: 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,ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY/BUSINESS OWNER[3 /OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTOTH)ej <br /> IfAPPL/CANT 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: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />