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SAN JOAQUAOUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> • SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f �Aao� s2.00 41 (0 q 9 <br /> OWNER/OPERATOR <br /> � p � CHECK If BILLING ADDRESS <br /> S 1i <br /> FACILITY NAME <br /> 17. ►' L cn vN VL 1 <br /> SITEADDRESS 37�� �CLc �jY ��tr rte ( -y 9S 37c. <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> DV jet Number Street Name <br /> CITY STATE ZIP <br /> Cp I U k I <br /> PHONE#1 ExrAPN# LAND USE APPLICATION# <br /> PHONE R Err. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS ���. <br /> BUSINESS NAM TY� ,# Exr• <br /> �✓ IBJ <br /> HOME or MAILING ADDRESS FAX# oyl)' <br /> ( ) <br /> CITY < - STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,Q� CN <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 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:6,- ;� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTMR AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IF RMATIO : When applicable,I,the owner or operator of the property located at the <br /> a1` •t add" hereby ••talio the release of a ..A all o-1+e —manhninnl `lata nnrl/nr PnvirnnmPntnl/site nsgPgsment <br /> V�ve �Iae address,s, .,a,, y a.a. .,aaa,,, „ a„vu�v v ..ny ,.a. .. .,, , bvv.vv••_..• <br /> information to theSANJOAQUIN COUNTY ENVIRONMENMAL 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: �� ��' PEU <br /> � <br /> COMMENTS: MAS 2 9 ZpQS <br /> SAN JOAQUIN COUNN <br /> ENOIRQNMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:io EMPLOYEE#: DATE: '� Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> ( <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date z <br /> Payment Type Invoice# Check# G ceiv By: <br /> EHD 48-02-025 SR FORM(Golden P"Ir <br /> REVISED 11/17/2003 <br />