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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# EXT. <br />ICE REQUEST # <br />FAX # <br />( ) <br />� � � �� <br />][—�SER <br />0--)q6 a3 <br />OWNER/ OPERATOR <br />LU <br />CHECK If BILLING ADDRESS O <br />COVN� <br />FACILITY NAME co <br />IN <br />SOA <br />SAN ONMEN�AENT <br />SITE ADDRESS ( / C I /A <br />U <br />J/ -� c7Clk/�`/ <br />Street Number Direction Street Name <br />city Zip Code <br />m <br />HOME or MAIL-17,DRESS (If Different froit Addresss) <br />EMPLOYEEM '� Z, <br />`/ x C Street Number <br />ASSIGNED TO: <br />Street Name <br />CITY <br />S7( l�Ts�✓ <br />ST E ZIP 9,S - <br />PHONE #1 EXT. APN # <br />LAND USE APPLICATION # <br />SERVICE CODE: C, (� <br />PHONE #2 EXT. <br />`) <br />BOS DISTRICTLOCATION <br />CODE <br />( a6- S' <br />Payment Date <br />Payment Type <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS El <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />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 a identified on this form. <br />I also certify that I have prepared this app c tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, A E and EDERAL aw . <br />APPLICANT'S SIGNATURE: Gt, DATE: �,2 4 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / NIA GE ❑ 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 <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_ NiA <br />TYPE OF SERVICE REQUESTED: (�( S T— C <br />C11 Aj.-� C AJ�A EIv�Ct <br />COMMENTS: <br />COVN� <br />IN <br />SOA <br />SAN ONMEN�AENT <br />H�� � ptrPA�jM <br />ACCEPTED BY: <br />L� L,t C _ <br />EMPLOYEEM '� Z, <br />DATE: 2_ ' 0�, <br />ASSIGNED TO: <br />C..( C <br />EMPLOYEE #: `i 3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: C, (� <br />PIE: <br />Fee Amount: <br />c 3 dL <br />Amount Paid tl ' _ <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 1, '; ✓ <br />Received By: 6 G <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />