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SAN JOAQUIN• UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Ty of Business or Property <br />o {1 <br />EN <br />FACILITY ID # <br />60(9 ? <br />SERVICE REQUEST # <br />5r -®c q 0,:3 w �c <br />OWNER/ OPERATOR, <br />CHECK if BILLING ADDRESS O <br />FACILITY NAME <br />SITE ADDRESS 3),S O <br />Street Number <br />Direction <br />Street Name <br />T <br />S�oLY�fi�,-� <br />city <br />19,S2 ' c� <br />ZID Code <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 />00'A `-N-14 'X11 2'' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Fee Amount: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME,, 11 <br />V �C O (` <br />ExT. <br />PH NE # 2 - <br />0 — 3J " <br />HOME or MAILING ADDRESS __ z <br />FAX # <br />� -6� <br />CITY STATE ()C"ZIP C <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, Stand ds, STATE and FEDERA laws. <br />APPLICANT'S SIGNATURE: DATE: V <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT o' L <br />If APPLICANT ' not he 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. „ %% PAYINA P n I -r <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />NOV 16 2004 <br />SAN JOAQUIN COUNTY <br />HEALTH DE ARTME <br />T <br />ACCEPTED BY: <br />EMPLOYEE #: G <br />DATE: C <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P / E:%� <br />(J <br />Fee Amount: <br />Amount Paid a C1 D <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # D7'1 <br />Received By: 2� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />