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SAN JOAQUIepUNTY ENVIRONMENTAL HEALTWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CLE <br />FACILITY ID # <br />SERVICE REQUEST # <br />60760 <br />OWNER/ 0ERAT R <br />C) <br />EMPLOYEE #: <br />G <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME ` S „d <br />ASSIGNED O: G <br />SITE ADDRESS 3l <br />Street umber <br />6. <br />Direction <br />Street Name) <br />CI zl, Cke <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />STATE ZIP <br />PHONE #f <br />(M) ' I - <br />EXT•APN <br /># <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />q�um <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME '('�, „ ^ <br />EMPLOYEE #: <br />G <br />PHONE #— EXT. <br />/ <br />ASSIGNED O: G <br />Ob <br />INGDDRESS <br />HOM7TL <br />FAx# <br />SERVICE CODE: <br />( 3 oa <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 <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, ST TE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <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. PAYMENT <br />TYPE OF SERVICE REQUESTED:' <br />7 <br />COMMENTS: 61 <br />AUG 10 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED <br />EMPLOYEE #: <br />G <br />DATE: a / G <br />ASSIGNED O: G <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P I E: 23 a�' <br />Fee Amount: a� <br />Amount Paid -63 (off . �� <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 />