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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />c� <br />SERVICE REQUEST # <br />PHONE#� � Exr. <br />� <br />I—A-6 00 <br />oC) <br />OWNER / OPERATOR <br />❑ <br />ACCEPTED BY: <br />�t <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />v <br />S lADDRESS <br />ASSIGNED TO: �. <br />c QUI <br />I r f <br />Street Number <br />Direction <br />me <br />Streett Name <br />PIE: 2-2 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />' 3 7T- <br />Payment Date <br />Street Number <br />Payment Type <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#Z EXT. <br />BOS DISTRICTLOCATION <br />CODE <br />( ) <br />C Z <br />U 1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR,„ r n �+I�� ` _ �� <br />(�L { 5 1 !V <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />c� <br />COMMENTS: �[ s �lo�t To a 9,-zFs-:z <br />PHONE#� � Exr. <br />� <br />HOME or MAILING ADDRESS <br />FAX# <br />7— r34� <br />CITY <br />STATE CP ZIP QS3`�7 <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 />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. 2� <br />APPLICANT'S SIGNATURE:_i��, �rn�ca-�-- DATE: <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: VVhen 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 assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED:i _, <br />�'Io <br />COMMENTS: �[ s �lo�t To a 9,-zFs-:z <br />�1 <br />O <br />AUG 1 3 2013 <br />ACCEPTED BY: <br />�t <br />EMPLOYEE #: j - 7 <br />DATE: E } TAL <br />v <br />t� [ <br />ASSIGNED TO: �. <br />EMPLOYEE #: �, ( <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: I��<- <br />PIE: 2-2 <br />Fee Amount:��-- <br />Amount Paid <br />' 3 7T- <br />Payment Date <br />($ /3 <br />Payment Type <br />Invoice # <br />Check # J/ ?/,2 <br />Received B <br />EHD 48-02-025 -SR FORM (Golden Rod) <br />07/17/08 <br />