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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTV FPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --E <br /> OWNER/OPE TOR <br /> C/ -r C7 nl / _{ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME J / <br /> STE ADDRESS c U a r / ,► ! � ) a /„`©� S��G <br /> 0 Street Number Direecction / / Street Name !/- Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. AP N# LAND USE APPLICATION# <br /> PHONE#Z Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � � / � � �— <br /> CHECK if BILLING ADDRESS❑ <br /> i <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRES 98' <br /> CITY 7' 7/7 ATE 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 or <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, TATE and FED RAL laws. / <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Z C) <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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: L— PAY vED <br /> COMMENTS: <br /> JAN 2 $ 2pp1 <br /> uN� <br /> Paw C��- <br /> SA�ZN <br /> H <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� PIE: �6D <br /> Fee Amount: c� Amount Paid 0-7-, , Payment Date (-o -2kj 1 <br /> Payment Type Invoice# Check# (o S ?jA Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />