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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />AUG 2 To .:. <br />CHECK If BILLING ADDRESS ED <br />FACILITY NAME �y/I <br />COUN <br />SITE ADDRESS 1 Z 5(' <br />7 Street Number <br />Direction <br />/ L <br />/V Street Name <br />H��}-i DEPAR�EN <br />ACCEPTED BY: <br />TCJ—�7,0,�F <br />City <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />ASSIGNED TO: <br />Street Name <br />CITY <br />C/ ' V <br />Date Service Completed (if already completed): <br />STATE oil <br />ZIP Gi <br />EXT. <br />PHONE #1 <br />P 1 E: <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT. <br />( ) <br />Payme t Date <br />BOS DISTRICT <br />Payment Type V1 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME /" PHONE# Q�/I ,2� EXT. <br />HOME DT�M,AII INor-,;,DRESSY �/D ` (Ax# )71', ,— 3 o b 3 <br />CITY �� 6A:f p4"" STATE ��� ZIP 4�� 2—Ob <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 th' lica ' nPEDEIR:AIL <br />t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stan rds, S A a laws. / <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER❑ O ERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLicANT 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: <br />pivmFgT <br />COMMENTS: <br />��'j <br />AUG 2 To .:. <br />COUN <br />SAt`IEMIIRONMENT <br />H��}-i DEPAR�EN <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 <br />f7-3`7,�-n -(-� <br />Payme t Date <br />Payment Type V1 <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 I [ SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />