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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typeo�Business or Property FACILITY ID# SERVICE REQUEST# <br /> '"yC U FAQs 2-42t 5 s'R8 <br /> OWNER/OPERATO <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADD S (If ifferent irqn Site Address) <br /> O0 4Y�O S reef Number Street Name <br /> CITY STATE ZIP ly <br /> an <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR E <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME- <br /> AME �� \ PH NE 2,2 _72 <br /> EXT. <br /> HOME or MAILING ADDRES ^ FAX# <br /> YV--, )Aok,&) �Ot)�'YsA <br /> ( ) <br /> CITY S TE 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. <br /> APPLICANT'S SIGNATURE: �/� /�'V^' f 6J DATE: -El-L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER I 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 tk same time it is <br /> provided to me or my representative. !JAy <br /> TYPE OF SERVICE REQUESTED: cei <br /> COMMENTS: MAY <br /> JOA <br /> �1RO)VMEN UNT)• <br /> H�EP,gRTM NT <br /> lt <br /> ACCEPTED BY: < EMPLOYEE#: DATE: <br /> ASSIGNED TO: , ! (� - EMPLOYEE#: DATE: 3 <br /> Date Service Completed (if already Completed): SERVICE CODE: /E: -0/� <br /> Fee Amount: G Amount Pai �S(� Payment Date /� 3 l� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />