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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />PH9�E# EXT. <br />� ' 3 b <br />HOME or MAILING ADDRE,S�1 I O � <br />I <br />A(^) � n (_ an'5�� <br />OWNER/ OPERATOR <br />STATE ZIP d, <br />�k <br />SAN JOAQUIN <br />CHECK If BILLING ADDRESS <br />FAULTY NAME <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />SITE ADDRESS <br />ASSIGNED TO: S <br />" <br />DATE: <br />Date Service Completed (if already completed): <br />Street Number <br />Direction <br />PIE:11- <br />Street Nam <br />cityZi <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />\2 7 tJ ?V <br />Payment Type✓ <br />Invoice # <br />Check # S ? (,Z'Received <br />By. K-& <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APNY <br />LAND USE APPLICATION # <br />1 1 a5a- X13 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r + I{ \ �I ( n <br />IlU1 A �� 1`(xv <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME - <br />1 oil <br />� <br />PH9�E# EXT. <br />� ' 3 b <br />HOME or MAILING ADDRE,S�1 I O � <br />I <br />A(^) � n (_ an'5�� <br />CITY I(` ���J11- -!� <br />STATE ZIP d, <br />�k <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 />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. jn <br />APPLICANT'S SIGNATURE: DATE..,,::!,, I a 0 / <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ M AGER ❑ OTHER AUTHORIZED AGENT 1LJ v�a <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sigh is reyuire�t[[// �� 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. �tT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />DEC 7 2007 <br />COUNTY <br />SAN JOAQUIN <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE:11- <br />Fee Amount: a ° <br />• <br />Amount Paid ais <br />, r�V <br />Payment Date <br />\2 7 tJ ?V <br />Payment Type✓ <br />Invoice # <br />Check # S ? (,Z'Received <br />By. K-& <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />