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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ISD # <br />F- A 7�y� <br />SSIRVICE RR'E; Q(UUEST # % <br />�1z- ice' l / 6e <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />HOME Or MAILING ADDRESS <br />SAN JOAOUIN COUNTY <br />FAX # <br />(�C�`) <br />SITE ADDRESS�,L <br />Street Number Direction W <br />l Street Name <br />( city t <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: Ll� <br />Street Name <br />DATE: <br />�v <br />CITY <br />STATE <br />ZIP <br />DATE: <br />PHONE #1 EXT.APN <br />( ) <br /># <br />LAND USE APPLICATION # <br />Date Service Completed (if already c pleted): <br />PHONE #2 EXT. <br />( ) <br />SERVICE CODE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \ <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />—, � � � I ,� � <br />PHONE# <br />c7zc <br />EXT. <br />HOME Or MAILING ADDRESS <br />SAN JOAOUIN COUNTY <br />FAX # <br />(�C�`) <br />CITY <br />STATE <br />ZIP pCl <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 business as identified on this form. <br />I also certify that I have prepared this appli 'on a at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S a E ERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 6 Z6 a�- <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT TIiQlrkl ( (/vIgn, T�L <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. fi <br />TYPE OF SERVICE REQUESTED: jT <br />R _ E I V,[ ) <br />COMMENTS: <br />JUN 213 20,)!':: <br />SAN JOAOUIN COUNTY <br />ENVIRONViENTAL <br />HEALTL I []EPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: Ll� <br />DATE: <br />�v <br />ASSIGNED TO: <br />EMPLOYEE M v�� <br />DATE: <br />(Aj% <br />b I v <br />Date Service Completed (if already c pleted): <br />SERVICE CODE: <br />P I E: <br />U <br />Fee Amount:Amount <br />Paid <br />Payment <br />Date (o 2- <br />Payment Type <br />Invoice # <br />Check # <br />Received By: Iv� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />