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SAN ,JOAQUIN d-'IUNTY ENVIRONMENTAL HEALTH "EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />04 <br />ACCEPTED BY: <br />PHONE# <br />(.n" <br />-F-7 f� ���`�d <br />S'10 0 3.sg 3 <br />.0 \ C-� c <br />FAX # <br />Qcc,) <br />Date Service Completed (if already completed): <br />CITY ` .�s� C 10-C <br />OWNER / OPERATOR <br />ZIP qS �2 O <br />Fee Amount: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />\ \ <br />�-oe�� m&r�n� <br />SITE ADDRESS (, n `i G1 <br />Invoice # <br />L rn �.j <br />Received By <br />Street Number <br />Direction <br />Street Name <br />C ty <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />EXT. <br />PHONED #1 <br />APN # <br />LAND USE APPLICATION # <br />G <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C'Y1 i w <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />tY\ V-9— <br />04 <br />ACCEPTED BY: <br />PHONE# <br />(.n" <br />EXT. <br />�►bl- 633 <br />HOME or MAILING ADDRESS <br />2S3S �, .���,-, (- <br />EMPLOYEE #: <br />FAX # <br />Qcc,) <br />Date Service Completed (if already completed): <br />CITY ` .�s� C 10-C <br />STATE O c, <br />ZIP qS �2 O <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: DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ NIANACER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT 's not he <br />ASe BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RE 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: <br />COMMENTS: <br />Zpp4 <br />�� 16 <br />J 1N GOVN['� <br />aU <br />$A JNW'-TVowe"', <br />fM AR MEt�C <br />mjapL <br />04 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date 7/1C <br />Payment Type `? C <br />Invoice # <br />Check # ( ) <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />