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Type of Business or Property <br />Owner I Operator <br />Facility Name <br />Site Address <br />City <br />Ext.APN # <br />Ext.BOS District Location Code <br />Requestor <br />) <br />^^3 /City Zip <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />& loSSo <br />Date:Employee #: <br />Employee #:Date: <br />Service Code: <br />Fee Amount:Amount Paid Payment Date <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <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 />1 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 />SERVICE REQUEST# <br />77? AD/ <br />Street Name <br />Street Number <br />Direction <br />76-3 7/ <br />Zip Code <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Su a/ <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Phone <br />Fax#I (_ <br />State <br />Phone #1 <br />r2.c‘]) 736<-7 <br />Phone #2 <br />( ) <br />Check if Billing Address <br />Check if Billing Address O <br />Date: <br />Property/Business Owner Operator/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 auf ■ • • - ■ •- ‘ ’ il data and/or environmenlal/site assessment <br />information to the San JOAQUIN >on as it is available andat the same time it is <br />provided to me or my representa ^54 <br />CONTRACTOR / SERVICE REQUESTOR <br />Business Name /fy <7O <br />Home or Mailing Address <br />_____________________City___________ <br />st. <br />____________________Street Name______ <br />State Zip <br />CAe_______/ <br />Land Use Application # <br />51 u) <br />,p/f:Kp.O\ <br />Received By: <br />Ext. <br />$ ; <br />Check # I <br />Accepted By: , WXxL-Yx/WV <br />Assigned to: sj . <br />Date Service Completed (if already completed): <br />Payment Type /€>