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WMT <br />SAN JOAQUIN COUNTY ENVIRON1viENTAL HEALTH DEPART1*vIENT <br />SERVICE REQ VEST' <br />Type of Business or Property <br />BUSINESS NAME n <br />FACILITY ID # <br />HOME Or MAILING ADDRESS <br />X�, 7/6 <br />SERVICE REQUEST # <br />6 <br />OWNER/ OPERATOR <br />ACCEPTED BY: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: <br />SITE ADDRESS <br />Street Number Direction <br />treet Name <br />city Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CIN <br />PIE: �I % , <br />div ! <br />Fee Amount: <br />STATE ZIP <br />P7 E #1' EXT. <br />APN # <br />Payment Date <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />Invoice # <br />Check # j _ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUESTOR. <br />REQUESTOR 1�y' <br />CHECK if BILLING ADDRESS LJ <br />BUSINESS NAME n <br />�T <br />PHONE - <br />HOME Or MAILING ADDRESS <br />X�, 7/6 <br />FAX # <br />( ) <br />CITY © kr TE ZIP r.,2 ri Ci <br />BELLING ACKNONVLEDGErlIENT: 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 projeci of <br />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�dFEDE laws. <br />APPLICANT'S SIGNATURE: <br />DATE•¢p <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/ NIANAGER ❑ OTHERAUTIIORizEnAGENT KJ _ <br />If APPLICANT is not the BILLINGPARTT, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE TWORNIATION: 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 ENv1RONiMENTAL 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: 5 / ,DA <br />C014MENTS: <br />�� Zp06 <br />JA r UNC I <br />„v 30F0'Jt*\ NJ L <br />ENVIRON QTt�1CP�i <br />ACCEPTED BY: <br />EMPLOYEE <br />ASSIGNED TO: <br />EMPLOYEE 4: 4=:�- DA <br />DATE: <br />Date Service Completed <br />(if already Completed): <br />SERVICE CODE: <br />PIE: �I % , <br />div ! <br />Fee Amount: <br />Amount Paid -* <br />` r j - <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # j _ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Ll <br />