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l SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR0�t <br /> CiAl CHECK if BILLING ADDRES <br /> FACILITY NAME <br /> SITE ADDRESS E�. <br /> Street Number Direction Street Name cit, Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) u L 1 S u ;( `-�/ <br /> Street Number 1" Street Name <br /> CITY Q�„�j'// STATE �A ZIP <br /> PH0Nlt#1) � � � �� � ..,ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 ) <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. 7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER[] OPERAT R/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 a same time it is <br /> provided to me or my representative. n <br /> TYPE OF SERVICE REQUESTED: � II\J`YiV 1F �(1✓( <br /> COMMENTS: 144 , 3 1 <br /> $ANj0A 2 23 <br /> Q()1 <br /> Fly <br /> H y lr M t <br /> FNT <br /> ACCEPTED BY: INV <br /> EMPLOYEE#: DATE: 2' <br /> ASSIGNED TO: A/VEMPLOYEE#: DATE: <br /> Date Service C mpleted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Cil Amount Paid I Payment Date 3l 2� <br /> J <br /> Payment Type a <br /> Invoice# G�ec# #. log Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />