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SAN JOAQL.., COUNTY ENVIRONMENTAL HEALTH „EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Rt+ -60 C,0-;0Iirf, -bi 5 o m1h <br />FAX# <br />CITY STATE zip <br />OWNER-/ OPERATOR <br />—Bo <br />CHECK If BILLING ADDRESS❑ <br />JLC Ih 4v\k- -rvw. <br />SERVICE CODE: <br />FACILITY NAME :tk -7 7 6 1 <br />Fee Amount: <br />SITE ADDRESS <br />15y <br />Payment Date <br />{� <br />ParkW�:� <br />�J�'txX`4ov. <br />`iS2l`� <br />1085 Street Number <br />Direction <br />tree Name <br />C Ity <br />Zio Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />—r� ip5 YL <br />`r <br />Street Number <br />lS eet Name <br />CITY <br />l tti. <br />STATE ZIP <br />z L- &017 - <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(841) BM-- OZ1 t{ <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE zip <br />BILLING ACKNOWLEDGEMENT: 1, 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 />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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: VaAAZ Q DATE: ZI -I log <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />/f APPLICANT is not the BILLING PARTY, proof of aul/rorilation 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: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />