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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUST <br />HOME or MAILING ADDRESS <br />FAx <br />CITY STATE ZIP <br />Q <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: 5zl l <br />SITEADDRESS Q7n2 Imo. <br />u lSttr�eett <br />/�w /2,&j <br />l I w <br />SERVICE CODE: <br />S7ta`f%f�i <br />Number DIreectlon <br />Street N me <br />Payment Type <br />CI <br />ZI Cotle <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />68eet <br />Nu mbar3 <br />re Nam¢ <br />CITY `% <br />r <br />STATE CO ZIP <br />APAPPLICATION <br />PHONE #1 EXT. <br />t ) q I � ' �'n-5- <br />APN # <br />LAND USE # <br />PHONE#2i/% �O EXT. <br />( ) jO (--� <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME /•' <br />PHONE# ENT. <br />HOME or MAILING ADDRESS <br />FAx <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 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 laws. <br />APPLICANT'S SIGNATURE: � �y7• �.�— DATE: <br />PROPERTY/ BUSINESS OWNER <br />l31 PERATOR/MANAGER ❑ 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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at tl�3fj1@ fljp��p provided to me or <br />my representative. 0 T merry � <br />TYPE OF SERVICE REQUESTED: <br />RE,GEI V CU <br />COMMENTS: /1 I , , , / \ <br />C/IV/l/.v/(IT/ (/�✓,V) <br />/I „ /q� f l � r Eg L4 201 <br />GU� vi tN, SAN JOAl2UIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPART MENT <br />ACCEPTED BY: <br />• "i <br />EMPLOYEE #: S [ q <br />// <br />DATE: 2 /"-l_ <br />ASSIGNED TO:H-ennj <br />EMPLOYEE #: 5zl l <br />DATE: 2- 2-12,117 <br />Date Service Completed (If Ilready Completed): Z 2 ! <br />SERVICE CODE: <br />PIE: 2 ' <br />Fee Amount: , bo <br />Amount Paid <br />Payment Date Y <br />Payment Type <br />Invoice # <br />Check # �, a �S 3 <br />Received By: l <br />J <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />