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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />e of Business or Property <br />�( <br />FACILITY ID # <br />SERVICE REQUEST # <br />NER / OPERATOR � I /� <br />CHECK if BILLING ADDRESS ❑ <br />�J C /�' <br />FACILITY NAME <br />I <br />ASSIGNED TO:TA <br />SITE ADDRESS <br />Street Number <br />I <br />Direc ion v <br />C aLYr ` cl5g s <br />Street Na e r l / city ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Fee Amount: - Q(J <br />STATE ZIP <br />PHONE #1 <br /><65 <br />ExT. <br />APN # <br />Invoice # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />I CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR TWO�/ CHECK if BILLING ADDRES <br />BUSINESS NAME <br />44 <br />PHONE# EXT. <br />(569 <br />HOME Or MAILING ADD SS�35 <br />FAX # <br />CITY STATE ZIP <br />BILLING ACk]gO L DGEMENT: 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 a li ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards T E and FEDE 1 <br />APPLICANT'S SIGNATURE: ' DATE• 5 /.ff <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ed <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is requir, 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: ^ Gf <br />PAYMENT <br />REeEiivEn <br />COMMENTS: <br />MAY 1 8 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: V LL v £+ `' <br />EMPLOYEE #:"Z/ <br />1 <br />DATE: <br />ASSIGNED TO:TA <br />EMPLOYEE #: / <br />DATE: <br />Date Service Completed (if already pleted): <br />SERVICE CODE: <br />P I El: <br />Fee Amount: - Q(J <br />Amount Paid <br />�,g S� �� <br />Payment Date b-7 <br />Payment Type <br />Invoice # <br />Check # g'q <br />Received By: <br />EHD 48-02-025 C`--- SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />