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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type ofiness or Pr e y <br />COMMENTS: <br />ACILITY ID # <br />SERVICE REQUEST # <br />r"' <br />SAN JOAOVIN <br />pEPAt4mRTPL MENT <br />lei J' <br />ACCEPTED BY: (� (� I (��( <br />L� o` J <br />EMPLOYEE M 03 <br />DATE: t' r� CJ <br />ASSIGNED TO: �. <br />EMPLOYEE <br />DATE: d (7 r <br />OWNER/ UPERAT <br />R <br />PIE: .3,() f <br />Fee Amount: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Payment Type <br />Invoice # <br />Check # / Z, <br />Received By: <br />SITE ADDRESS Cj� <br />/ /-h9 <br />O ,j <br />1Y <br />J <br />C( <br />SZip <br />Street Number <br />Direction <br />Street <br />Citv Code <br />HOME or MAILING ADD SS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT•APN <br /># <br />2 � —U <br />LAND USE APPLICATION # <br />( g <br />�2- <br />PHONE #2 <br />EXT. <br />BOS DISTRICT _ <br />LOCATION CODE <br />( ) <br />REQUESTOR <br />n CONTRACTOR / SERVICE REQUESTOR a <br />CHECK if BILLING ADD <br />BUSINESS NAME Znj� j� �l/// //L�fY l\ V L PHONE# 7/� `l/I 33 7T <br />HOME or MAILING <br />FAx # <br />CITY '/—\ --4' /A /l .1,n - (' / A STATE 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 app c tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S AT and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE:*Titl <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ElOTHER AUTHORIZED AGENTIfAPPLICANT is not the BILLING PARTYproof of authorization to sign is reguire <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 />NQS 1 2QO1 <br />NTM <br />GutAO <br />SAN JOAOVIN <br />pEPAt4mRTPL MENT <br />ACCEPTED BY: (� (� I (��( <br />EMPLOYEE M 03 <br />DATE: t' r� CJ <br />ASSIGNED TO: �. <br />EMPLOYEE <br />DATE: d (7 r <br />Date Service Completed ( already completed): <br />SERVICE CODE: I <br />PIE: .3,() f <br />Fee Amount: <br />Amount Paid <br />Payment Date C` 0 —7 <br />Payment Type <br />Invoice # <br />Check # / Z, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />