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4 46 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />ACCEPTED BY: �I (f <br />11 <br />5400 a <br />OWNER/ OPERATOR <br />ASSIGNED TO: /t('� <br />EMPLOYEE#:•"•) %, / <br />"L <br />J <br />CHECK If BILLING ADDRESS <br />IL` <br />6� <br />FACILITY NAME ��. <br />Fee Amount: �. <br />Amount Paid <br />Z�. D -D <br />Payment Date <br />SITE ADDRESS i �o <br />Payment Type <br />Invoice # <br />Check # 2— <br />6 Sty 4 Street Number Direction <br />Street Name <br />Ci 0 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />lj qd SI Lf <br />p -{ <br />Street Number <br />Street Name <br />CITY>L.STATE <br />"` <br />Zip <br />C4 9.5- u <br />PHONE #1 EXT. <br /># <br />LAND USE APPLICATION # <br />7PN <br />I? -IIID- % <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTOR �k' CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# ExT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: - DATE: 24 A 12-, � <br />PROPERTY / BUSINESS OWNER ❑. OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPL/CANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: 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 />riwvur7wrr <br />TYPE OF SERVICE REQUESTED: ST � ('e WOF' w <br />(I ow v <br />;RECEIVED <br />COMMENTS: <br />APR - 4 2011 <br />z;,A JOAQUIN COUNI <br />ENVIRONMENTAL <br />11-TH DEPARTME <br />ACCEPTED BY: �I (f <br />EMPLOYEE #: <br />DATE: (L l <br />ASSIGNED TO: /t('� <br />EMPLOYEE#:•"•) %, / <br />"L <br />DATE: <br />` i <br />Date Service Completed (if already completed): b�T <br />SERVICE CCOODDE✓: <br />6� <br />P / E: <br />Fee Amount: �. <br />Amount Paid <br />Z�. D -D <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 2— <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />