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SAN 3OAQUIT` OUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME "L G l j <br />FL4HOME <br />SERVICE REQUEST # <br />S�-�iOti1 <br />orMA1LIN�G7ADDRESS /P_ ��`®�( <br />A� 's W r <br />r <br />CITY :S 1 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILrrY NAME <br />Fee Amount: <br />'� (1 1 e manli i�tYr1 <br />Payment Date <br />ADDRESS <br />SITE B <br />Invoice # <br />�i i� 1 f e— rruxn <br />t l 'T 7l <br />Received By: <br />Lo � <br />®�� (� <br />7 <br />Street Number <br />Dir on <br />Street Name <br />Ci <br />2i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />REQUESTOR <br />r `® <br />CHECK if BILLING ADDRESSET <br />BUSINESS NAME "L G l j <br />FL4HOME <br />EMPLOYEE #: <br />PHONE # _ / ExT. <br />FAX# CD �/ <br />.., &37 <br />orMA1LIN�G7ADDRESS /P_ ��`®�( <br />A� 's W r <br />r <br />CITY :S 1 <br />STATE ff ZIP 9 <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 JOAQu1N <br />COUNTY Ordinance Codes, Standard TATE and FEDERAL laws._ <br />APPLICANT'S SIGNA DATE: �� 9' 08 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT (GG <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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <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 / E: <br />Fee Amount: <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 />