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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />,Type of Business or Property <br />MAR, <br />FACILITY ID # <br />SERVICE REQUEST # <br />1.11 il <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAMI! <br />ASSIGNED TO: <br />SITE ADDRESS <br />Street Number <br />Direction <br />�/ <br />i <br />Street Name city <br />ZI Code <br />e <br />HOME Or MAILING ADDRESS (If Different from Site Address) /% 7 <br />`v Street Number <br />�//�` <br />�/ e <br />�S�N.. <br />CITY / //� <br />[�h <br />STATE/ZIP 2 j,77 <br />- 7 G� <br />PH NE # EXT, <br />Payment Date <br />APN # <br />LAND USE <br />SE APPPPLIICATION # <br />PHONE #2 EXT. <br />( ) <br />Check #� J Z <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <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: t !. DATE: L <br />PROPERTYBUSINESS OWNER OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />FPLICANT 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 as ormation <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same timer or <br />my representative. QF�VP� <br />TYPE OF SERVICE REQUESTED: <br />MAR, <br />COMMENTS: <br />Sq N OAOQU/ty COON TY <br />yFALTy pE ARM L <br />iVr <br />ACCEPTED BY: A /! /% C+ r v <br />V l <br />`D l(� <br />EMPLOYEE #: <br />DATE: 7 I'n I <br />ASSIGNED TO: <br />�J ' y�J z <br />I v <br />EMPLOYEE #: <br />DATE: /4� I -7 <br />lk <br />Date Service Completed (if already completed): <br />SERVICE CODE: = ` `-ice <br />PIE : <br />O <br />Fee Amount:LA <br />1 <br />Amount Pa' L� 17 0 <br />Payment Date <br />3//�- /17 <br />Payment Type <br />Invoice # <br />Check #� J Z <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />