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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTROPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�V f eit 0C (d. , Re ❑ <br />�/ CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />P7# O�� j ��� Exr. <br />o <br />EMPLOYEE #: Lt O'SO <br />6eCC 6 (-13 ,1-f <br />CITY / S� f!Y1 <br />STATE ZIP Cf%' S74 3 <br />EMPLOYEE #: �L(, 4-G <br />DATE: Z4,' <br />OWNER / OPERATOR <br />SERVICE CODE: <br />CHECK If BILLING ADDRESS <br />Ahc - <br />Fee Amount: <br />FACILITY NAME . t5 l j <br />Payment Date <br />G <br />/ <br />Invoice # <br />SIE ADDRESS <br />I <br />'�" <br />1 L Q.• ) j <br />,Street <br />(� <br />` <br />Alva Street Number <br />Direction <br />Name <br />C <br />2i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #1 <br />EXT- <br />APN # <br />LAND USE APPLICATION # <br />PHONE #1 <br />( D <br />EXT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r: <br />i�� � j,��l ,,ps,, <br />(� fT/iLr�(C/aP"C J <br />�V f eit 0C (d. , Re ❑ <br />�/ CHECK If BILLING ADDRESS <br />BUSINESS NAME In , /� <br />��(l fA©e �/��r <br />J�d� <br />P7# O�� j ��� Exr. <br />HOME Or M� D <br />EMPLOYEE #: Lt O'SO <br />1 / <br />(71A) 90 / " 1117 <br />CITY / S� f!Y1 <br />STATE ZIP Cf%' S74 3 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Z DATE: .2XUtA�0/,;2- <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY_proof Of authorization t0 sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />— <br />COMMENTS: 4,� - % /� <br />6-,v b f <br />ACCEPTED BY: C <br />EMPLOYEE #: Lt O'SO <br />DATE: /- <br />ASSIGNED TO: � J <br />EMPLOYEE #: �L(, 4-G <br />DATE: Z4,' <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid ffi 3 75: 0 <br />Payment Date <br />(o Y <br />Payment Type <br />Invoice # <br />Check # Zq <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />