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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty f Business or Property FACILITY ID# SERVICE REQUEST# <br /> �e,�0e a-h`4A <br /> OWN"OP RATOR <br /> �7Il �t� J ��` ,` o e� <br /> FACILITY NAME CHECK if BILLING ADDRESS <br /> O� <br /> SITE.ADDRESS Street Number I Direction "� �� Name Zi Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ? �3 - Do 1) <br /> PH 92 xT. BOS DISTRICT "> LOCATION CODE <br /> J` <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME P Ext. <br /> HOME Or G DDR SFAX# <br /> /Y? ( ) <br /> CITY STAT ZIP n <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 a plication and that the work performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE and FERE laws. <br /> APPLICANT'S SIGNATURE: Alma DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICA 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 t0 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: Sv, j��+ }c?�i I Y PJ. .f�c� }C `-o� L(I ��GC� /C.F V , <br /> COMMENTS: VLC� <br /> �7 <br /> J0, O C IJ�2� <br /> E9Lrh p� �7AL rY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: A EMPLOYEE#: DATE: L/ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: (� Amount Paid 0 r Payment Date <br /> Payment Type Invoice# Check# 21 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />