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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />4 <br />SERVICE REQUEST # <br />Sr2 o v & 0 &37 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILrrY NAME <br />OL U� L j�/4 <br />SITE ADDRESS <br />Street Number Direction v'1 <br />Street Name C ity IZip Code <br />HOME or MAILING ADDRESS (If Different from Site Addres <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />Fee Amount: <br />BOS DISTRICT <br />LOCA�QN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� <br />CHECK If BILLING ADDRESS Ef <br />BUSINESS NAME i <br />1 % _ (a33T <br />HOME Or MAILING ADDRESS\C� <br />Ll 6 <br />CITY7T6 C M 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 I ws. <br />APPLICANT'S SIGNATURE: �p DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ THER AUTHORIZED AGENT ❑ <br />IfAPPLiCANT 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. <br />TYPE OF SERVICE REQUESTED: Us <br />COMMENTS: <br />oL z 9 201,0SAN <br />HEW E "IONI N COON <br />7}.q DE MNTALTM&7Y <br />ACCEPTED BY: - <br />OL U� L j�/4 <br />EMPLOYEE #: ()3 -2 -(DATE: <br />2� <br />ASSIGNED TO: <br />�� G/� �J t '� <br />EMPLOYEE #: ( ( 2 Z <br />DATE: 2 1 1 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: L 71f-� <br />P 1 E: 2-3 09�11 <br />Fee Amount: <br />3 � <br />Amount Paid <br />� — <br />Payment Date 'f 12A ) I D <br />Payment Type <br />✓ <br />Invoice # <br />Check # (l{ �j <br />Received By: 66 <br />EHD 48-02-025 SR FORM(Golden°Rod} <br />REVISED 11/17/2003 <br />