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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OA OR <br /> J / CHECK If BILLING ADDRESS <br /> FACILITY NAMI() <br /> (� V `lC- S-' ,IU� <br /> SITE ADDRESS <br /> f��/��►,� /�7 <br /> W Co I v `6ta'Nu�� ..ion ON�e ��Cf Zip Code <br /> TH ME or MAILING ADDRESS (If Different from Site Address) <br /> 01• Y ( Street Number Street Name <br /> CITY,^� �nG� n �� i_ STATE ! , �IP <br /> PHONE#1 't /i ExT• APN# oi -o 0-7 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COD <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 thi lication and that the work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta ar=STE F DERAL I w . <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> lfAPPL/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: Ss I v L S re V e <br /> COMMENTS: <br /> c�fl o'�,/17/ZD?-D Sq AN <br /> "JO ?0?0 <br /> ACCEPTED BY: 1' Z— EMPLOYEE#: DATE: T <br /> ASSIGNED TO: / v EMPLOYEE#: DATE: 6I �C)�O <br /> Date Service Completed (if already Completed): SERVICE CODE: S J 3 PIE: a 6 p L;� <br /> Fee Amount: 0 Amount Paid f Payment Date <br /> Payment Type Invoice# Check:# Received By: <br /> EHD 48-02-025 v u 3 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />