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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT 0 <br />EPARTMENT <br />0 SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />n FACILITY ID # <br />PAYMENT <br />�REQUEST # <br />SERVICE <br />OWNER / OPERATOR M <br />ts <br />CHECK if BILLING ADDRESS <br />FACILITY NAME D P <br />STATE C ZIP gO6.Z1 <br />SITE ADDRESS <br />9suNumber <br />Direction <br />,� n <br />fV� 1�1` S'treetName,U L <br />Ci <br />Zi C✓odee� <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />ACCEPTED BY: ` O� <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMPLOYEE #: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR\N A\� � P (� <br />CJ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PAYMENT <br />PH NE# Exr. <br />!6 <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY <br />STATE C ZIP gO6.Z1 <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 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 PARa 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 />lIZA l <br />PAYMENT <br />COMMENTS: <br />J U L 2 8 2004 <br />SAN JOAOUIN COUNTY <br />ENIVIRONWNtTAL <br />HEALTH DEPARTMENT1 <br />ACCEPTED BY: ` O� <br />lv� <br />EMPLOYEE #: <br />DATE: 'l 2� <br />ASSIGNED TO:�/� <br />J <br />EMPLOYEE #: f <br />DATE: --72A <br />d-1 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: z 3o ' <br />Fee Amount: `1 i a) ,ob <br />Amount Paid , <br />Payment Date —] ( 0 L,1 <br />Payment Type <br />Invoice # <br />Check # l 3 q <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />