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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =S40y4WJ0 <br /> ERVICE REQUEST# <br /> UU I 13 <br /> OWNER/OPERATOR r <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS t/Jm" M7 Bv <br /> Street Number I Direction v Street Name Cit 7 ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> .I W �� T. Street Number Street Name <br /> CITY STATE zip // n <br /> n 1 G(/ <br /> PHONE#1 Exr APN# LAND USE APPLICATION# <br /> (zo9 )7 --2.o <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM. <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 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. r <br /> APPLICANT'S SIGNATURE: �. r CA_�� I(�� 0 �� DATE: <br /> PROPERTY/BUSINESS OWNERV OPERATOR/MANAGER ❑ `-' OTHER AUTHORIZED AGENT IS <br /> If APPLICANT 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 the or my representative. 1� <br /> TYPE OF SERVICE REQUESTED: Pr <br /> COMMENTS: <br /> ACCEPTED BY: LA 661 S r EMPLOYEE#: 10 DATE: 14 Z'L <br /> ASSIGNED TO: Kadf /! EMPLOYEE#: DATE: J Z <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: �o Amount Paid I �� Payment Date ( J 72 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />