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J <br />... ,a. vv.a�va.� vvvi�i l iii 11a\Vi�i�li'J1�1AL 11JL/AL ll\1iI11L1\1 <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE# - <br />EMPLOYEE #: <br />OWNER PERATOR <br />HOME Or MAILIN DQRESS/I p i ©� <br />❑ <br />1 <br />t C J <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY L,4 in d <br />STATE ZIP <br />SERVICE CODE: <br />P I E: <br />SITE ADDRESS <br />41w4umber <br />1 <br />J <br />Diu di n <br />Street Name <br />City Zio Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # ���� <br />Received By: <br />(A Street Number <br />Street Name <br />CITY / y y/y <br />(/i <br />STATE ZIP <br />PHONE#1 EXT. <br />APN # <br />LAND USE APPLICATIO # <br />cry) 32�1'- D7 <br />PHONE #2 ExT <br />) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS ❑ <br />A <br />a, (S'W <br />COMMENTS: <br />BUSINESS NAME <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE# - <br />EMPLOYEE #: <br />HOME Or MAILIN DQRESS/I p i ©� <br />ASSIGNED TO: I <br />(AX#) �� J� oy <br />t C J <br />DATE: <br />CITY L,4 in d <br />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: DATE: �iT2/Z�J(a <br />PROPERTY/ BUSINESS OWNER ❑ OPERAT / 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 <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 availab qA Lhp f4me time it is <br />provided to me or my representative, PEC— EiVED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: I <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />J <br />Payment Date <br />Payment Type "I, - <br />Invoice # <br />Check # ���� <br />Received By: <br />EHD 48-02-025 YR FOfIN=,'(�olde"r"Rod} <br />REVISED 11/17/2003 <br />