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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FA('11 ITv In L SERVICE REQUEST# <br /> li <br /> oo <br /> OWNER/OPERATOR <br /> " CNF�BKIfBILLING OD <br /> NA-iA 2 <br /> FACILITY NAME <br /> Y <br /> SITE ADDRESS <br /> c) Street Number Direction tc,lf4 me <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE 41 ExT. A N# LAND USE APPLICATION# <br /> Lo <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> San Joaquin County Aging and Community Services CHECK if BILLING ADDRESS® <br /> BusiNEss NAMENVEXT. <br /> ) 468-3895 <br /> HOME or MAILING ADDRESS FAX# <br /> PO BOx 201056 <br /> CITY Stockton STATE CA zIP 95202 <br /> BILLING ACKNOWLEDGEMENT: 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE; DATE: <br /> PROPERTY/BUSINESS OWNERE] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTX,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 environmentaUsite 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 /> P-JDJ� +11 <br /> TYPE OF SERVICE REQUESTED: C o-V-kA,1-,A,(A <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): 06- SERVICE CODE: P I E: <br /> Fee Amount: Payment Date Amount Paid I 1A <br /> Payment Type Invoice# Check# q I Received By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 0 <br />