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SAN JOAQUIN COUNTY ENVIRONAIENTAL HEALTH DEPARTI\'IENT <br />SERVICE REQUEST <br />T e of Busin ss or Property <br />'�O'bw <br />BUSINESS NAME' <br />Cea)haeht-s <br />FACILITY ID # <br />SERVICE REQUEST # <br />� <br />F <br />:0�1-72-- <br />�6 <br />O /N ER / OPERATOR <br />' <br />❑ <br />EMPLOYEE #: J7 <br />(� <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ' <br />k r <br />SERVICE CODE: <br />PIE: <br />►� <br />Amount Paid <br />w <br />SITE ADDRESS -701 <br />Wala: <br />'' <br />Street Number <br />irection " - <br />Name / City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />A �A <br />STATE ZIP <br />PHONE #t <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION C DE <br />n CONTRACTOR / SERVICE REQUESTOR <br />CHECK If BILLING ADDRESS <br />REQUESTOR afi <br />BUSINESS NAME' <br />Cea)haeht-s <br />PHONE T EXT. <br />� ) -k <br />HOME Or iVtA1LING ADDRESS /--�g- � <br />� <br />F <br />CITY STATE 6S <br />Jr <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 app)' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, A E and FEDE laws. <br />AALICANT'S SIGNATURE: G ' DATE: �7 <br />ky" <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGE ' G ,G <br />t4), <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. ��.� l� ; f'•S I <br />TYPE OF SERVICE REQUESTED: US -r <br />COMMENTS: <br />`�A1 ZDOb <br />SAND JO cv 'Jlt'$ COUNTY <br />ENVISONMEidTAL <br />HEALTH DEPAVI _I`4 <br />ACCEPTED BY: // <br />�J <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: J7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: U'p <br />Amount Paid <br />w <br />Paym <br />nt Date <br />Payment Type <br />Invoice # Check # 1 SCA � <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />