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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />��� <br />FACILITY ID # <br />BUSINESS NAME <br />S RVIICCE6REQUSTTT #g <br />'`'U -� `c dT <br />PHONE # ExT. <br />Z2J' <br />U r�" <br />f 7 C <br />OWNER OPERATOR_Tr <br />HOME or MAILING ADDRESS <br />r kLi %PFWI <br />CHECK If BILLING ADDRESS <br />` <br />Charles <br />i <br />P aev <br />7v,- <br />c ) <br />FACILITY NAME <br />DATE: <br />ZIP <br />SITE ADDRESS <br />'g <br />(" <br />GT-Siode <br />Date Service Completed (i already completed): <br />Street Number <br />Direction <br />5<tree <br />P 1 E: y <br />Fee Amount: "' <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�J ,Street <br />Payment Date - —� <br />Street Number <br />Name <br />CITYSTATE <br />L- 8 t <br />Check # - ��' `, <br />ZIP <br />CC4- <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT'(( <br />LOCATION C DE <br />Cl <br />( 1))OUB{ <br />CONTRACTOR / SERVICE REQUESTOR , <br />REQUESTOR <br />"bb <br />r <br />��� <br />� U / �YY CHECK if BILLING ADDRESS <br />/ <br />BUSINESS NAME <br />%%-rr e-1--/ <br />'`'U -� `c dT <br />PHONE # ExT. <br />Z2J' <br />U r�" <br />f 7 C <br />f, c9/O- <br />HOME or MAILING ADDRESS <br />` <br />FAX # <br />9 <br />P aev <br />7v,- <br />c ) <br />CITYSTATE <br />DATE: <br />ZIP <br />/ <br />EMPLOYEE #: <br />BILLING ACKNOWLEDGEME T: I, the undersigned property or busin o r, 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 />also certify that I have prepared this application and that eel rmed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT ERAL laws <br />APPLICANT'S SIGNATURE: DATE: Z/// <br />PROPERTY / BUSINESS OWNER ❑ OP OR % MANAGER OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is n e BILLING PARTY, proofof authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It Is provided v <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />(. (% Cc�G <br />`S'gArJ <br />✓. �- Gvnrn Q vrl <br />'`'U -� `c dT <br />IA <br />d71 �i') FpAyCOMMENTS: RgCOti�O <br />i21R <br />-kin�l;0 <br />f 7 C <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: ��. <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (i already completed): <br />SERVICE CODE: <br />' <br />P 1 E: y <br />Fee Amount: "' <br />Amount Paid / / • D'!� <br />Payment Date - —� <br />Payment Type i✓ <br />Invoice # <br />Check # - ��' `, <br />Received By: - <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />0611 <br />N4, <br />T <br />