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SAN JOAQUAOUNTY ENVIRONMENTAL HEALTH. _PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />O , <br />FACILITY ID # <br />PHONE # EXT. <br />3 y'12, 9 6 <br />SERVICE REQUEST # <br />1/ <br />643 //9 - �'i <br />CITY !l�� T TE ZIP/j� <br />_ <br />s <br />SAN JOAQUIN COUNTY <br />ENVIROEMARTMENT <br />n <br />OWNER / OPERATOR <br />D <br />BILLINGADDRESSE] <br />�L V �C./�� <br />EMPLOYEE #: 70 <br />CHECK If <br />FACILITY NAME <br />�/G B I/ <br />EMPLOYEE #: <br />SITE ADDRESS <br />Date Service Completed (if already completed): <br />w <br />�� <br />SERVICE CODE: (,f <br />•_ <br />PIE: <br />Street Number <br />Direction <br />/�� /�j �St e[ N.ZX <br />Payment/t Date <br />Ci <br />Zi Codei <br />HOME Or MAILING ADDRESS (If Differ from Site Address) <br />���"`555 <br />/f <br />Street Number <br />r t �i/a/me <br />CITY / <br />S TE ZIP _ <br />PHONE #1 EXT.APN <br /># <br />LAND USE APPLICATION # <br />�� 3 �-1 //--16 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />O , <br />BUSINESS NAME <br />PHONE # EXT. <br />3 y'12, 9 6 <br />HOME or MAILING ADDRESS ✓ L/ <br />FAX # <br />CITY !l�� T TE ZIP/j� <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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,STATE FEDERAL la <br />APPLICANT'S SIGNATURE: DATE: �h <br />PROPERTY / BUSINESS OWNER ❑ RATOR / 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 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. <br />TYPE OF SERVICE REQUESTED:/ <br />PAYMENT <br />COMMENTS: <br />APR 2 8 2014 <br />SAN JOAQUIN COUNTY <br />ENVIROEMARTMENT <br />D <br />ACCEPTED BY: (;v � p/D <br />EMPLOYEE #: 70 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: (,f <br />PIE: <br />- <br />Fee Amount: , -�-7 � <br />Amount Paid <br />3'jS — <br />Payment/t Date <br />Payment Type kV <br />Invoice # <br />Check # ap(p (P <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />