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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />• SERVICE REQUEST - <br />Type f Busines or Property <br />u �'�i <br />FACILITY ID # <br />PHONE XT. <br />( ) <br />SERVICE REQUEST # <br />'"04 7 �3 I <br />OWNUR / OPERATOR <br />CITY STATE ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME (LiZ <br />SAN JOAQUIN COUNTY <br />SITE ADDRESS q b 3 y� <br />Street Number Direction J <br />I �� <br />Street Name <br />` �/�� fm A ,. 9,55 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 1 <br />T <br />Street Number <br />ACCEPTED BY: <br />tree amt <br />CITY <br />EMPLOYEE #: <br />ATATE ZIP <br />PHONE #1 * 1 EXT. <br />APN # <br />ASSIGNED TO: <br />LAND USE APPLICATION # <br />PHONE #2 —i -n,5 P"WN— — <br />( () '39 a - 115-153 <br />EMPLOYEE #: 0 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE XT. <br />( ) <br />HOME or MAILING ADDRES % �� <br />FAx 4& ' �k3 -1-2— <br />CITY STATE ZIP <br />J <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 this ap4ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandardsATIrE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �I /Gf/1J DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ElOTHER AUTHORIZED AGEfi' LJE <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 />,_,,\ \/nn. G <br />N"V <br />TYPE OF SERVICE REQUESTED: <br />RECEIVED <br />COMMENTS: <br />ANp8200 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />DEPARTMENT <br />HEALTH <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: 0 <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />PIE: —� <br />Fee Amount: <br />Amount Paid <br />�95 <br />Payment Date l C <br />Payment Type <br />Invoice # <br />Check # 6 / q / 2_— <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />