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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT�DEPARTMENT <br />0 SERVICE REQUEST <br />Type ofMs�rUpe <br />�,1� <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />3 V7 9 <br />SERVICE REQUEST # <br />OWNER / PERATOR <br />I <br />HOME Or MAILIN ADDRESS i , j�' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />CITY STATE A <br />ZIP <br />SITE ADD E <br />�t)t Street Number <br />tion <br />ACCEPTED BY: <br />/�H� <br />re ame `�� <br />DATE: <br />j %J/�j <br />/ C K' " <br />q t,"'iJ/, <br />�`ZlIi�CJodOOe�C Vv <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE#1 � � � � � � Exr. <br />APN # <br />Payment Type - <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Received By: <br />BOS DISTRICT <br />LOCATION CODE <br />n1 CONTRACTOR / SERVICE REQUESTOR <br />I / <br />REQUEST � n <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />/- EXT. <br />HOME Or MAILIN ADDRESS i , j�' <br />( <br />/ —6,3!Y2 <br />CITY STATE A <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 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 applica o ' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT a FEDERAL la <br />APPLICANT'S SIGNATURE: DATE: / Z-MUQ' <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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. B!q YA 4M, W <br />TYPE OF SERVICE REQUESTED: bC S T "-T-40 F l <br />HECK+L-I V I <br />7— <br />COMMENTS: <br />COMMENTS: <br />AP 2 <br />DUB <br />SAN,10 <br />liN RONM COUNTY <br />FACTH <br />DFpgR MINT <br />ACCEPTED BY: <br />EMPLOYEE #: % Zr <br />DATE: <br />ASSIGNED TO:ti, <br />EMPLOYEE #: S�, Y <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( 4' <br />PIE: .23C>d <br />Fee Amount: �; <br />Amount Paid <br />` <br />Payment Date <br />Payment Type - <br />Invoice # <br />Check # \ 2 'l= <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />