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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NA <br />SERVICE REQUEST # <br />r� e . <br />?73,15;- <br />HOME or MAILING ADDRESS <br />1-142 CICS 70 do 3' <br />OWNER / OPERATOR <br />CITY STATE ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ACCEPTED BY: Psif i <br />EMPLOYEE #: <br />— <br />DATE: ,,,Pj/ <br />ASSIGNED TO:EMPLOYEE <br />d <br /># <br />SITEADDRESS <br />Date Service Completed (if already completed): <br />— SERVICE CODE: <br />P 1 E: e <br />Fee Amount: � q 0 <br />Amount PW <br />��� <br />Payment Date <br />r <br />Payment Type �S� <br />Invoice # <br />0;2 e— / q <br />Rec ive By: i <br />UT7 Street Number <br />Direction <br />hsEt e�l C 1 <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Sfreet Number <br />N <br />CITY <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />ft) - (-1 I <br />SEP 2 5 2014 <br />PHONE #2 ExT. <br />t )EKI <br />BOS DISTRICT <br />11POKIINA NITAI HAIIH <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQU15"MMENT <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NA <br />PHONE# EXT' <br />L <br />HOME or MAILING ADDRESS <br />FAX# <br />CJ <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ M A ER ❑ OTHER AUTHORIZED AGEN'r <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 />COMMENTS: C01 a <br />- E <br />E� ? <br />� <br />-10A <br />, <br />H m�AVAI <br />E <br />647 <br />ACCEPTED BY: Psif i <br />EMPLOYEE #: <br />— <br />DATE: ,,,Pj/ <br />ASSIGNED TO:EMPLOYEE <br />d <br /># <br />I D G— <br />Date Service Completed (if already completed): <br />— SERVICE CODE: <br />P 1 E: e <br />Fee Amount: � q 0 <br />Amount PW <br />3,70.6 6 D <br />Payment Date <br />Payment Type �S� <br />Invoice # <br />0;2 e— / q <br />Rec ive By: i <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />