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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS sec e <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />ACCEPTED BY:iSS� <br />� <br />EMPLOYEE #: <br />DATE: <br />OWNER / OP TOR//-- <br />S ' <br />� � &,e-, G �A , CNECK If BILLING ADDRESS <br />J <br />FACILITY NAME <br />Date Service Completed ' already completed):j <br />SIJE ADD <br />SERVICE CODE: �, <br />yll�[///���1 <br />41q <br />PIE: <br />� T L^CI � <br />' <br />/ /�SS <br />Street Number <br />Direction <br />Street Nam' a <br />Invoice # <br />I Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY 5 f'/'C f /lJ <br />STAYE ZIP / 2— <br />PHONE #1 EXT. <br />(awW OKI <br />APN # <br />(GySC'b <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />BOS DISTRICT ' 1 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQ STOR /J ^ <br />,�,/ CHECK If BILLING ADDRESS <br />/P /40',7 / <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS sec e <br />FAX # <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 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 the rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL Ia Q <br />APPLICANT'S SIGNATURE: �(�ii7 �� i�O DATE: J /� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ THER 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is provided t0 me or <br />my representative. 40 <br />A. <br />TYPE OF SERVICE REQUESTED: S 1 -C S <br />} C'rh (C n MPC ,' ^ <br />COMMENTS: <br />G(tY'ay� Ccrnec�•G� <br />eA- ✓ s3 ^ 7� 7 <br />+ f Se , to <br />V p'��(.. C�/1 I <br />ti '�i,R ��18 <br />CTjyO 4r'�F�O�N <br />pgRT rye �Y <br />ACCEPTED BY:iSS� <br />� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: W o n <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed ' already completed):j <br />Z <br />SERVICE CODE: �, <br />PIE: <br />Fee Amount: �� I S 2 <br />Amount a' <br />S� on <br />Payment Date &W <br />Payment Type C% <br />Invoice # <br />Check #3o2,2- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />