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Igo SERVICE REQUEST <br />of Business or Property <br />EMPLOYEE #: <br />FACILITY ID # <br />SERVICE REQUEST # <br />I/e <br />,�} <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />8 <br />1 P 1 E: Z <br />Fee Amount: 7J ! <br />Amount Paid <br />I OV"INE /OPERATOR <br />Payment Date <br />(� <br />Payment Type ✓ <br />Invoice # <br />CHECK If BILLING AO RESS <br />FAC,uTr Nan <br />ce5 <br />SITE ADDRES 6 <br />Street Number <br />Direction treet Name Cit Zi Code <br />HOIAE or MAILING ADDRESS (If Different <br />from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PhiGNE 91 <br />Exr. <br />APN # <br />LAND USE APPLICATION # <br />j PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />i <br />I11L1.1\G ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of s:imv, <br />.t�:inuwledge that all site and/or project specific ENVIRONMENTAL-HFALTH DEPARTMENT hourly charges associated with this piojcci o: <br />:,Cu%ity will be billed to me or my business as identified on this form. <br />D1'11-30 certify that 1 have prepared this application a that the work to be performed will be done in accordance with all S.' -.N Ji .v,. <br />OUNTY Ordinance Colles, Standards, STATE a DERAL laws <br />/� PLIC,�NT'S SIGNATURE: DATE: <br />PROPERTI / BUSINESS OWNER El OPE OR/ AlANAGER OTIIER AUT110RIZED AGEN'r ❑ <br />IJ'APPLICANT is not the BILLING PARTY, prop authorilzation to sign is required --- <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located ut u;(: <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessnicm <br />infonnation 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: Pf,YNI,EN <br />CONWENTS: <br />AUba J 1 2006 <br />SAN JOAQUIN COIJ `ITY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />,�} <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />8 <br />1 P 1 E: Z <br />Fee Amount: 7J ! <br />Amount Paid <br />8 S" CZ) <br />Payment Date <br />(� <br />Payment Type ✓ <br />Invoice # <br />Chegk # <br />U 2 Z <br />Received By: <br />EHD 48-02-025 <br />RE':'iSED 11/17/2003 <br />M <br />SR FORM (Golden Rod) <br />