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SAN JOAQUIi " BOUNTY ENVIRONMENTAL HEALT0EPARTMENT <br />SERVICE REQUEST <br />Type f Business or Property <br />2Z/�j/x,00le/ <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />COMMENTS: <br />SITE ADDRESS <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY Shc K y // /ur <br />STATE (i 14 ZIP <br />PHONE #1 ExT7 <br />(2aq) 9L1k- &i�-W 7 <br />ACCEPTED BY: <br />EMPLOYEE #: 3J10 <br />LAND USEAPPLICATION # <br />PHONE #2 EXT. <br />( ) DAY- SylSl <br />ASSIGNED TO: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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. /, `/ 7 �) <br />APPLICANT'S SIGNATURE:0 i/F�� DATE: — ��— V 7 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ 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 available and at the same time it is <br />provided to me or my representative. PAYMENT <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />RECEIVED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JUL 10 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: 3J10 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: /L <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type,7 <br />I <br />Invoice # <br />Check # <br />Received By:HS <br />,�" <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />