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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />• SERVICE REQUEST <br />sin s or Property <br />FACILITY ID # <br />Llj� V)� <br />SERVICE REQUEST # <br />Tvf <br />3.7 9, <br />PHONE# zz EXT <br />LF� <br />l' <br />_ ,-2 D /- <br />O NER / OPERATO <br />D0--,a' f h <br />SAN JOAQUIN COUNTY <br />FAx # <br />(.;;ZdI ) <br />�-+ CHECK If <br />BILLING ADDRESS <br />FACILfTY NAME / � <br />/� . <br />G✓ ,%, , nA^� t'1�E -1 <br />SITE ADDRESS <br />EMPLOYEE #:DATE: <br />Street Number Directi <br />Street Name <br />C. <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />PIE: p Si <br />Street Number <br />v� <br />Street Name <br />Payment Date SCO -7 <br />CITY Y Yv— <br />STATE ZIP <br />Cheek # laa� <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION ODE <br />J CONTRACTOR / SERVICE REQUESTOR <br />jol <br />REQUESTOR <br />! S' <br />Llj� V)� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME` <br />0. Y2c <br />PHONE# zz EXT <br />LF� <br />6E:P 2 0 2007 <br />( �) W cJC3 <br />HOME or MAILI ADDRESSF—`,, <br />SAN JOAQUIN COUNTY <br />FAx # <br />(.;;ZdI ) <br />CITY <br />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' <br />s a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TATE and FEDERAL ws. <br />APPLI,CANT'S SIGNATURE: C DATE: 912-01V <br />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 />! S' <br />RECEIVED <br />COMMENTS: <br />6E:P 2 0 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:DATE: <br />2 t9 (; 7 <br />ASSIGNED TO: <br />EMPLOYEE #: ��� <br />DATE: Gy Z� c 7 <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />PIE: p Si <br />Fee Amount: 4�� <br />v� <br />Amount Paida- G L. C -p <br />Payment Date SCO -7 <br />Payment Type tj <br />Invoice # <br />Cheek # laa� <br />Received By: `7� <br />EHD 48-02-025 - .SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />