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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6U AW-s c/tj S 3 <br /> OWNER/OPERATOR <br /> � ( CHECK if BILLING ADDRESS <br /> FACILITY NAME , <br /> M 7/1 L / T/-� <br /> SITE ADDRESS <br /> Street Number Dire tion 5• l/� / Qtidet Names TD Cl'Cityp Code <br /> H?E 5E or ADDRESS (If Different from Site Address) <br /> (p- Sro L Street Number Street Name <br /> CITY STATE zip <br /> C_r v C^ o 2 /S <br /> PHONE#1 Ext• 7— <br /> A # LAND USE APPLICATION# <br /> PHONE#2 Ez. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE III Ex . <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CIN 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 SIGNATURE: f��ti n DATE: _ S Z <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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: ,J <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: �'u� DATE: <br /> ASSIGNED TO: I -, MPLOYEE#: I f DATE: <br /> Date Service Comp ted (if alreadi completed): Li SERVICE✓CODE: h f pit: <br /> Fee Amount: Amount Pai U� Payment Date <br /> /S� <br /> Payment Type Invoice# Check# H GSS C Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />