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wo SAN JOAQUII, _OUNTY ENVIRONMENTAL HEALTH _c:PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />o a' G r I G1 �r / ✓t <br />FACILITY ID # <br />�./ <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDRESS <br />DATE: <br />SITE ADDRESS <br />StreettNumber <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 <br />Fee Amount:U� <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />Payment Date <br />APN # <br />Payment Type <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Check # a� <br />Received By: IY P- <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR/ /I�G 1�' <br />o� <br />CHECK If BILLING ADORES <br />BUSINESS NAME <br />(j <br />e� <br />ENV/ qQ�t <br />H�T� DOVp� noJ rY <br />NT <br />PHONE# <br />1 zo <br />EXT. <br />S3f>- 39 -7/8 <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX # <br />I .?o <br />) <br />CITY e 5 <br />STATE C �j <br />ZIP c �O <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 <br />or activity will be billed to me or my business as identified on this form. <br />1 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, STME and FEDE L laws. pry <br />APPLICANT'S SIGNATURE: D:vFE: Aog r j�• <br />PROPERTY/ BUSINESS ONN'NER❑ OPERATOR/ MANAGER ❑ OT HER AUTHORIZED AGEN061M ` /n — �t° <br />arlaa e 4— gtt 4.y6Zt'1 I/ <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tille / <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 theAame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Ae-pleZC&t�Jo�-j <br />(j <br />e� <br />ENV/ qQ�t <br />H�T� DOVp� noJ rY <br />NT <br />ACCEPTED BY: <br />EMPLOYEE #: Z <br />✓ <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: / <br />P I E: <br />Fee Amount:U� <br />Amount Paid ��� <br />Payment Date <br />3 0 <br />Payment Type <br />Invoice # <br />Check # a� <br />Received By: IY P- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />