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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busipes or PropFACILITY ID# ERVICE REQUEST# <br /> OW E / ( __3 <br /> O,PAPERATOR <br /> CHECK if BILLING ADDRESS51 <br /> FACILITY NAME FAr <br /> SITE ADDRESS <br /> r, rI`} 9 <br /> Street Number Die Ion tre t � v <br /> HOME Or MILiNt ADDRESS (If Different from Site Address) <br /> Street Number �St�et Name <br /> CITY STAT P <br /> PHONE#1 EXT. APN# LAND OSE APPLICATION# <br /> �S ® <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C 0 <br /> ( ) <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 under gned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific VIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business identified on this form. <br /> I also certify that 1 have prepared this p tion and that the wor be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , S TE a DERAL I <br /> APPLICANT'S SIGNATURE. DATE: ,'^ v 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is no the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO REL ASE 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: bo yrs try q6�:��C""�✓SPG' Sepr1C }ti1��C, <br /> COMMENTS: IFS' COOC� lfi0i'1 OF 5 5'fe01 , / 11 <br /> Y �e/�ry IP-(.Jt1Y7PCTloYN. )M � <br /> C� I I (d c)CJ)C S3 ' 7(i 7 1D Se h ecl u if )"Spec-I%O 17 iv 9 <br /> 6 ENVI nQ 2020 <br /> C <br /> 01 JAI— <br /> ACCEPTED BY:r�P-1 1� EMPLOYEE#: / DATE; NIN <br /> ASSIGNED TO: S EMPLOYEE M DATE: ap.?Q <br /> Date Service Completed (if already completed): SERVICE CODE: OF P I E: yam <br /> Fee Amount: Amount Paid a Payment Date <br /> Payment Type l' Invoice# , )3g2q Received By: <br /> T. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />