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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> C) Q-) o � 3 � 1 UU �S� 15y <br /> OWNER / OPERATOR <br /> ` � i CHECK If BILLING ADDRESS <br /> V1C � � v 1 <br /> FACILITY NAME <br /> N>� °, V-\6 CCS <br /> SITE ADDR;Sl� 1 al J C� n ./ 1 � �(� Z66 <br /> �L L V Street Number Direction Street Name "`Cit Zip Code <br /> HOME or <br /> MAILING ADDRESS (if Differerom Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> 6 ,, <br /> PHONE #Z J EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> o �I `, CHECK If BILLING ADDRESSD <br /> BUSINESS NAMEEXT. <br /> ( HONE # ) <br /> HOME or MAILING ADDRESS ` 1 J FAX # <br /> CITY � � n 1� �cn STATE C'm ZIP 9S' 2o� <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, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE ; t 1 ( tl 'PROPERTY / BUSINESS OWNER OPERA OR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to Ire or my representative . 1 A <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : APR <br /> SAN ' 4 ?022 <br /> EJaAQutN you <br /> N�ITH CEPgR M L <br /> ACCEPTED BY : {� .� EMPLOYEE # : OQ3) DATE: <br /> ASSIGNED TO : 411 EMPLOYEE # : V U DATE : ILw ?L <br /> Date Service Completed (if already completed ) : t . �� / SERVICE CODE : PIE : <br /> Fee Amount : ii I U Amount Pal ! S� Payment DateIL �y <br /> Payment Type Invoice # Check # b Recei ed By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />