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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />• SERVICE REQUEST <br />Ty a of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />.. SERVICE REQUEST <br />O ER /OPE <br />TO <br />Q <br />j 6�1 ` <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />tot <br />COUNr(. <br />SITE ADDRESS <br />Streett ub Direction <br />V �/ShE�et� <br />i �l�► v Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Ad s) <br />Lumber <br />Street Name <br />CITY <br />ACCEPTED BY: / <br />STATE <br />0A <br />7mO <br />5 <br />PHONLJJ <br />ExT. <br />-6lo) �9 <br />ASSIGNED TO: I(� <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />Date Service Completed (if already completed): <br />BOS DISTRICT <br />LOCATION CO <br />721 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME"Ad' <br />COMMENTS: <br />P % „ (-633 3? <br />J <br />HOME Or MAILING ADDR <br />j 6�1 ` <br />F^ ) %„ ' � r / <br />`/ <br />`� �ziP <br />CITY <br />S <br />� <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 bu to ss as identified on this form. <br />I also certify that I have prepared d4s ap lication and that the work to be performed will be done in <br />COUNTY Ordinance Codes, Standa s, S TE and FEDERAL la <br />APPLICANT'S SIGNATURE: '�I/ `� DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is require <br />with all SAN JOAQUIN <br />,,\\ <br />Tit <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 />L ,AYME <br />COMMENTS: <br />2 6 2001 <br />jUN <br />COUNr(. <br />QUIN <br />sA EN R.�M �[ <br />1�pNM <br />pEPA <br />HEpd.TN <br />ACCEPTED BY: / <br />EMPLOYEE #: 3 Q <br />DATE: <br />ASSIGNED TO: I(� <br />EMPLOYEE #: ` <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />8 <br />P I E: <br />Fee Amount: 2 vC> <br />Amount Paid <br />a2 S <br />Paymeni <br />Date <br />Payment Type L/, <br />Invoice # <br />Check # <br />Received By: 'Gf� <br />EHD 48-02-025 - tltd� 'Fr4d) <br />REVISED 11/17/2003 <br />