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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Ab SERVICE REQUEST <br />Type of Bu si <br />s or.Pro <br />BUSINESS NAME � <br />FACILITY ID # <br />PHOS') � ��' <br />SERVICE REQUEST # <br />OWNER/ O <br />RATOR <br />CHECK if BILLING ADDRESS El <br />FACILITY NAME <br />CITY <br />$T ZIP <br />SITE ADDRESSWaAi-r.l.t <br />Street Number Direction <br />20d <br />�.e <br />Zip Code <br />HOME Or MAILING ADDRESS If'Different from Site Address) <br />i <br />Street Number <br />Date Service Completed (if already completed): <br />Street Name <br />CITY <br />� <br />Fee Amount: <br />STATE ZIP <br />P�HO�/NE#1 <br />"_- / ) <br />EXT. <br />- / 9 <br />APN # <br />Invoice # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />/ CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Lju_',�N <br />/C <br />l <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME � <br />� <br />PHOS') � ��' <br />HOME or MAILING ADDRESS <br />FAX # <br />ENVIRONMENTAL <br />CITY <br />$T ZIP <br />-z, . - <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 ap c tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDER91' <br />S. <br />APPLICANT'S SIGNATURE:Llii�� / DATE: I <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTYY, 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 />w A r- ts l l <br />TYPE OF SERVICE REQUESTED: S <br />rN <br />CEIVED <br />COMMENTS: <br />SEp 1 8 ZN7 <br />COUNTY <br />SAN JOAOUIN <br />ENVIRONMENTAL <br />HEALTHDEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: X p <br />v <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: �j <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />iL 91 If <br />Paymen Date `I' C) <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Goldep Rod) <br />REVISED 11/17/2003 <br />