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SAN JOAQUI14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />GPV5 <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />r <br />RAM <br />/L'�'�j I <br />f <br />(� <br />CHECK If BILLING ADDRESS <br />FACILITY DAME /� I " <br />n <br />STATE �- ZIP <br />SI�A�essqZode <br />/x Street Number <br />Direction <br />Street Name <br />Date Service Completed (if already completed): <br />Cit <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />P 1 E: <br />Street Name <br />CITY <br />, D <br />Payment Date y/ El/ I <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />Check # �3 DS <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO / <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />COMMENTS: <br />PONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY -�—_ <br />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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, .Standards,ATE and FEDERAL laws. f <br />APPLICANT'S SIGNATURE: t �DATE: <br />PROPERTY/ BUSINESS OWNER 9- OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is not the BILLING PALTT proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 saPAt,�I —NT <br />provided to me or my representative. ,. J �_I�1� t `T 1'� EIVED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />SAN JOAQUIN <br />ENV1RONME <br />DEPAF <br />ACCEPTED BY: �L I ` t <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: — J ri <br />EMPLOYEE #: 2(fl �( <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( l 6 <br />P 1 E: <br />Fee Amount: � � (.; , 0-V <br />Amount Paid $ 3 b b <br />, D <br />Payment Date y/ El/ I <br />Payment Type ✓ <br />Invoice # <br />Check # �3 DS <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />01i <br />OUNTY <br />TMENT <br />