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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST tl <br /> oY] .!tea <br /> OWNER 1 OPERATOR _ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMES <br /> SITE ADDRESS <br /> Street Number Direction , treat Nam City -ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) <br /> CITY SlreetNumber Street Name <br /> J STATE zip <br /> PnC'NE;1 ExT. i APN# LAND USE APPLICATION# <br /> PHC!E»Y f ExT BCS DISTRICT LpCATTON CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Tom &/o C e h CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME ExT.t°w tSfp r�1�n 9� s of wa PHONE <br /> HOME or MAILING ADDRESS PAX# <br /> CITY STATE zip <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,ST TE-and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 tom'im iZ <br /> If'APPLIC is not the BILLING PARTY 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, geotechnicai data and/or environm ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an tYJ <br /> t is <br /> provided to me or my representative. CEIVEQ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY. �!1 EMPLOYEE#: O 3 r DATE; <br /> ASSIGNED TO: V I EMPLOYEE#: 03I N DATE; <br /> Date Service Completed (if alread completed): SERVICE CODE: p r <br /> 41 <br /> Fee Amount 11 M. % <br /> � UU Amount?aid Z Payment Date <br /> Payment Ty Invoice# Check# S Re <br /> ce[ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> REVISED 1 1/1 71200 3 ) <br /> i <br />