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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property , <br />FACILITY ID # <br />EMPLOYEE #: <br />SERVICE REQUEST # <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed)/ <br />SERVICE CODE: a <br />PIE: <br />Fee Amount: <br />OWNER / OPERATOR <br />L' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Payment Type•� <br />SITEADDRES�S _ <br />Check #�,�1W� I �2 `Zt f <br />l�11 <br />!7-+�-X <br />1,;2-'—'y" Street Number <br />Direction <br />Street <br />Cirdl <br />ZiCode <br />HOME Or MAILING ADDRESS (If Different from <br />to Addres ) <br />IXJIT <br />Street Number <br />Street Name <br />CITY <br />S c?= 1 <br />STATEn ZIP <br />PHONE #1 EXT. <br />42(J- 9 <br />APN #LAND <br />a? <br />USE APPLICATION It <br />-�3y�AJs <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION OD <br />CONTRACTOR / SERVICE REQUESTOR t <br />REQUESTOR <br />CHECK If BILLING ADDRES <br />BUSINESS NAME PHONE # EXT. <br />HOME or MAILING ADDRESS FAX# <br />( ) <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 />I also certify that I have prepare thi application and that the c to be erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa s, TAT AL I <br />APPLICANT'S SIGNATUR : DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERA R AGER ❑ 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 />to the SAN JOAQUIN COUNTY ENVIRONMEWA -NTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It Is provided to me or <br />my representative. 7 <br />TYPE OF SERVICE REQUESTED: -,3F d If ) I IJ V Mt a44SVUAI'(6k ®� <br />COMMENTS: CY Cq,V`-�J �V m/ <br />r <br />vu 2' '�157-c--144 .0 7 3 —p16 a Z�) <br />F Oq <br />N NVi Q�/N <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: F HT <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed)/ <br />SERVICE CODE: a <br />PIE: <br />Fee Amount: <br />Amount Paid 152 _, <br />Payment Date <br />911 t I i <br />Payment Type•� <br />Invoice # <br />Check #�,�1W� I �2 `Zt f <br />Received By: <br />r <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />X018 <br />ry <br />YT <br />