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SAN JOAQL -OUNTY ENVIRONMENTAL HEALT- EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> a Q C- C' y- <br /> SITE ADDRESS IZ D S <br /> Z7l � � ! <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( < ) )7 O t <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 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 NATURE: �� Y°/1 � DAI�C: Y + � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 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: p0 t,� �j t� PAy <br /> COMMENTS: 1� IV V1 <br /> JA <br /> N -9 2014 <br /> HEADHOUi�COU <br /> Th pfPq NT,4CNT Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: t G <br /> I <br /> ASSIGNED TO: �r-� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l P I E: <br /> Fee Amount: Z y" 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 />