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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br />SERVICE REQUEST <br />T of Business <br />Property. <br />P ON F-# ExT.A) „ / <br />HOME Or MAILING A RESS � � � <br />FACILITY ID # <br />CITY STATE ZIP ql-51�Z05 <br />SERVICE REQUEST # <br />COVN� <br />Ol)IN <br />SA EN\JIRONME TMEW <br />HEALTH DEPAR <br />ACCEPTED BY: �, L t L G (��� - <br />OW R / OPERATO <br />74111 <br />� - 5 <br />ASSIGNED TO: `, , _ <br />CHECK If BILLING ADDRESS ❑ <br />FACILfrY NAME <br />� <br />C CL <br />P E: <br />Fee Amount: J <br />Amount Paid 1W a?"g-s—, ut� <br />SITE ADDRES <br />r <br />Street umber <br />Invoice # <br />V V <br />t Name <br />Zip Code <br />HOME or MAILING ADDRESS (If DVferent <br />from it Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #i <br />90q) `�2 <br />Exr. <br />- lav <br />APN # <br />1 =� - r L � -'r� <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />n CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS <br />REQUESTOR �M.1(i <br />BUSINESS NAME U� aC�i � n / <br />P ON F-# ExT.A) „ / <br />HOME Or MAILING A RESS � � � <br />FAX# /j f,, / <br />T C.0 ( 32— <br />CITY STATE ZIP ql-51�Z05 <br />BILLING ACKNOVEDGEMENT: 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 or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have preparedthis appli on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST E nd FEDERAL laws. <br />APPLICANT'S SIGNATURE:1 DATE: 2 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT q L2f <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 <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. . r-- t' 11 <br />TYPE OF SERVICE REQUESTED: L,(, S T <br />(�—t= -).—)c I —t / PAS IEIVE0 <br />COMMENTS: <br />loo? <br />^v <br />COVN� <br />Ol)IN <br />SA EN\JIRONME TMEW <br />HEALTH DEPAR <br />ACCEPTED BY: �, L t L G (��� - <br />EMPLOYEE #: .2- <br />DATE: cS 'ZZ(C <br />ASSIGNED TO: `, , _ <br />EMPLOYEE #: (.1 <br />DATE: c= <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ! G <br />P E: <br />Fee Amount: J <br />Amount Paid 1W a?"g-s—, ut� <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 />