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SAN JOAQUIIVUNTY ENVIRONMENTAL _HEALTH II-ARTMENT <br />SERVICE REQUEST <br />Type oof//f B``uussin s or Property -5711-1 -109" <br />t'1 L 6 lD 4f 49 <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER I OPERATOR y► fir- <br />zs r�apfu r� 134 <br />HOME or MAILING ADDRESS <br />3 <br />CHECK if BILLING ADDRESSE] <br />FACILITY NAME <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />SITE ADDRESS,' <br />IVVZ - Street Number Direction <br />Street Name <br />STATE cc? ZIP e <br />Ci <br />_ Zi Code <br />HOME or MAILING ADDRESS {]f Different from Site Address) <br />Street Number <br />Check # <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #'1 ExT. <br />{ } <br />APN # <br />LAND USE APPLICATION # <br />RHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR f SERVICE REQUESTOR <br />REQUESTOR91 <br />CCCC <br />y � �T 6 J `'V'� g ��_# �. 6:K � H <br />K.& C � / CHECK If BILLING ADDRESS <br />i (PHONE# <br />BUSINESS NAME '� <br />EMPLOYEE #: <br />EXT. <br />HOME or MAILING ADDRESS <br />3 <br />EMPLOYEE <br />FAX # <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />CITY *; <br />STATE cc? ZIP e <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 !rte or my business as identified on this forth. <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 la S. <br />APPLICANT'S SIGNATURE: DATE: <br />El <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR NAGER El OTHER AUTHORIZED AGENT -0 <br />IfAPPLICANT is not the BILLING PAR 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 <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 1 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 Rad) <br />REVISED 11/1712003 <br />