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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINvSt <br />SERVICE REQUEST # <br />PHONE ExT.�G <br />�����5 <br />o f 3�� <br />OWI /OPERATOR <br />CHECK If BILLING ADDRESS O <br />HOME or MAADDRESS <br />FAX # <br />S-ogILING <br />FACIL TY Na <br />Mi" <br />TE ZIP S i' <br />CITY S) SX <br />I U <br />DATE: � r �f <br />ASSIGNED TO: <br />SITEADDLRES <br />EMPLOYEE #: <br />DATE: <br />S� <br />J S� )U� <br />! <br />q-5 ZD <br />L Street Number <br />Directio <br />D�" <br />treat Name <br />Payment Date <br />Cit <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Received By <br />I / S r t L 1�[� <br />SStreet <br />NumberF <br />K <br />�F t (Street Name <br />CITYW h5� <br />A STATE Z � <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(22')l ) �— <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU rTOR <br />CHE,C_K If BILLING ADDRESS <br />(of) CkLjC <br />BUSINvSt <br />ME <br />PHONE ExT.�G <br />201 <br />7 <br />s <br />aoUtty <br />HOME or MAADDRESS <br />FAX # <br />S-ogILING <br />D PA M NT <br />TE ZIP S i' <br />CITY S) SX <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that [have prepared this ion a d t at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa s ST an ED RAL laws. 1 <br />APPLICANT'S SIGNATURE: - DATE: Il//Z1J <br />PROPERTY/ BUSINESS OWNER ILJ RA34 /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />tfAPPLICANT 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 environment site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and all"* <br />' <br />provided to me or my representative. c.� <br />TYPE OF SERVICE REQUESTED: <br />(of) CkLjC <br />vto <br />t <br />COMMENTS: <br />201 <br />s <br />aoUtty <br />N� you lo <br />HST y <br />D PA M NT <br />ACCEPTED BY:V t t A n <br />EMPLOYEE #: �jq, <br />J V <br />DATE: � r �f <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: lU'' (S� <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />