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NAN JOAQI-TIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of B iness or Prope <br />FACILITY ID # <br />SERVICE REQUEST # <br />IV <br />REC)JJ1 lNT <br />HOME or MAILING DDRESS <br />OWNER PERATOR�,',' /_ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ZIP <br />SITE ADDRESS �I --fir <br />FN A4U/N C <br />HEALTH �E MEIc 'qt <br />Street Number Direction` ' —` Stt2tTlame `'� .0-40* <br />Ci <br />HOME or MAILING AnDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />ASSIGNED TO: &fiEMPLOYEE <br />Street Number <br />#: <br />Street Name <br />CITY STATE <br />ZIP <br />PHONE #1 !xr. <br />(�'"h 3(P $-8 I <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />IV <br />REC)JJ1 lNT <br />HOME or MAILING DDRESS <br />FAxy# <br />(':Ro ) <br />/ <br />CITY d( STATE <br />ZIP <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL ws. <br />APPLICANT'S SIGNATURE: l C DATE- <br />PROPERTY/ <br />ATE: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: 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 />IV <br />REC)JJ1 lNT <br />V G� ✓ <br />APR . <br />sqN Jo <0&8 <br />FN A4U/N C <br />HEALTH �E MEIc 'qt <br />ACCEPTED BY: j1 /1 <br />EMPLOYEE #: <br />ASSIGNED TO: &fiEMPLOYEE <br />#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVIC'E/CODE: / <br />P I E: 0 <br />Fee Amount: 2 <br />Amount Paidaci4 <br />D 0 <br />Payment Date p� <br />Payment Type <br />Invoice # <br />Check # �1 g S' <br />Received By: <br />EHD 48-02-025 SR FORIa "(Golden Rod) <br />REVISED 11/17/2003 <br />