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X <br />SAN JOAQU -OUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�, <br />FACILITY ID # <br />a i' <br />gYMENT <br />SERVICE REQUEST # <br />si�-o Q s (,e 33E <br />OWNER / OPERATO <br />HOMEt Oj AI�NGADDRESS <br />CHECK If BILLING ADDRESS <br />FACILITY N ME <br />) f <br />0ZIP <br />CITY STATE <br />SITE ADDRESS <br />Street Number <br />S <br />Di 1 o <br />�v I <br />N e <br />H&TH DEPAA <br />—�'[.�–� <br />C <br />�.J �U�S <br />zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />ASSIGNED TO: /, I� <br />Stml Name <br />CITY <br />DATE: C - <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />Fee Amount:3 15 00Amount Paid <br />w <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />Payment TypeInvoice # <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />R ?UESTOR <br />CHECK If BILLING ADDRESS <br />gYMENT <br />SI ESS 16&E <br />PHONE # EXT. <br />HOMEt Oj AI�NGADDRESS <br />FAx# <br />� <br />(f�/ <br />) f <br />0ZIP <br />CITY STATE <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 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, STA7 and FEDERAL laws. <br />X APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAER OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY p of authorization to sign is required Twe <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 environmentaUsite 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: a <br />U <br />gYMENT <br />COMMENTS: <br />IAN 2 �� <br />B EWRONMEPfZ <br />H&TH DEPAA <br />ACCEPTED BY: V <br />EMPLOYEE #:,&01,5 <br />DATE: 1 /d a 6 , <br />ASSIGNED TO: /, I� <br />EMPLOYEE #: Cj09 <br />DATE: C - <br />Date Service Completed (If alrea Ieted): <br />SERVICE` CODE:/ <br />0 <br />PIE: a3 <br />Fee Amount:3 15 00Amount Paid <br />w <br />TL j 47 -Payment Date <br />C <br />Payment TypeInvoice # <br />Check # �3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />14n <br />LNT <br />