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SAN JOAQUIN 0UNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORCHECK <br />'16 1/11-) 1 1-nVv1 <br />Type of Business or Property <br />FACILITY ID # <br />j�21 CMQO <br />SERVICE REQUEST # <br />4— � <br />OWNER / OPERATOR <br />�; \ CHECK if BILLING ADDRESS <br />FACILITY NAME Odo ( \ 9-7 <br />I <br />FAx <br />SITE ADDRESS <br />Street Number <br />Direction <br />�/��a `�,\ <br />Street Name <br />(j <br />city <br />`002 <br />Zip Code <br />SERVICE CODE: <br />HOME or MAILING ADDRESS (If Different rom Si e(A dress) <br />` et Number <br />f� ndbe;r M e <br />Street Name <br />Amount Paid I s, <br />CITY Aobo^ � STATE ce ZIP v X02, <br />�(J <br />( l <br />Payment Type <br />ExT. <br />PHONE #1 <br />ApN #1 <br />LAND USE APPLICATION # <br />Received By: . <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORCHECK <br />'16 1/11-) 1 1-nVv1 <br />if BILLING ADDRESS <br />V<� <br />BUSINESS NAME ' <br />Fac <br />PH E i(/ -/ T. <br />HOME Or MAILING ADDRESS <br />FAx <br />CITY {C n STATE q ZIP 52�5 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ql- 11 1 myj—t DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ +t <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 />TYPE OF SERVICE REQUESTED: I I <br />COMMENTS: Cha i -t fo(brW <br />5=P _ OK sEto <br />J O <br />1 ° <br />CO <br />y THS pME90u, <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: �`'° <br />Amount Paid I s, <br />Paymen Date q fz S/6 <br />Payment Type <br />Invoice # <br />Check # -� 2ct <br />Received By: . <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />T <br />