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SAN JOAQUIN&LINTY ENVIRONMENTAL HEALTIWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />(-tv� -,c <br />PHONE# <br />`" <br />EXT. <br />HOME or MAILIG ADDRESS <br />0.7 f <br />OWNER / OPERATOR <br />C ��--1.1 �, ~- �Cx. U -� C e^ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME 1 A c j` j` -4 <br />T L}) _ <br />lh I l�� <br />CITY VC kk� <br />STATE �.jc\ <br />SITE ADDRESS <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: LJ <br />1L1C�'J Street Number <br />Dirac <br />Street Name <br />Cit <br />21 Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />H <br />�� ( � C? <br />3V C <br />Street Number <br />Street Na e <br />CIN <br />STATE <br />14 <br />ZIP <br />PHONE #1 E777 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />q ) Aq-5alaic <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR C (�� <br />pAYME p <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMF� \_ <br />PHONE# <br />`" <br />EXT. <br />HOME or MAILIG ADDRESS <br />0.7 f <br />3 <br />FAX # <br />(-(-' 1) <br />pE �y71FEN <br />CITY VC kk� <br />STATE �.jc\ <br />ZIP <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 <br />or 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: A 4DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATCfi/ ANAGER OTHER AUTHORIZED AGENT El <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: L✓( <br />pAYME p <br />COMMENTS: <br />SAS JOR0I t <br />EtN <br />pE �y71FEN <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: LJ <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount:7 ' <br />Amount Paid <br />3V C <br />Payment Date 1 <br />Payment Type <br />Invoice # <br />Check # <br />�' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />