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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHI)EPARTMENT <br />0 SERVICE REQUEST 6 <br />Type of Business pr Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />� j <br />0a'a k !/(V <br />" <br />HOME Or MAILING ADDRESS <br />OWN / OPE R <br />CITY STATE ZIP <br />MAR 3 0 2005 <br />CHECK If BILLING ADDRESS <br />i <br />FACILITY NAME <br />G <br />SAN JOAQUIN COUNTY <br />SITE ADDRESS <br />ddlj9l�MA <br />ACCEPTED BY: C L _ <br />lalldtO� <br />/�1 <br />;Z Street Number <br />Direction <br />St eet Name <br />DATE: <br />� Voa� <br />HOME or MAILIN DDRESS (If Different from Site Address) <br />SERVICE CODE: <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #'I EXT. <br />APN # <br />LAND USE APPLICATION # <br />#2 EXT. <br />--]PHONE <br />BOS DISTRICT <br />LOCATION CODE <br />n CONTRACTOR / SERVICE REQUESTOR <br />REQUESTQR <br />? CHECK If BILLING ADDRESS <br />BUSINESS NAME IV /I, <br />PHO / _ ` EXT. <br />G <br />HOME Or MAILING ADDRESS <br />F�Ax## <br />dam/ �) <br />CITY STATE ZIP <br />BILLING ACKN6WLEDGEMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand ds STATE and FEDERAL laws. <br />� ---k-ltu <br />APPLICANT'S SIGNATURE: IDATE:" " <br />, <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT a <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. <br />TYPE OF SERVICE REQUESTED:PAY <br />NI EN -r <br />COMMENTS: <br />MAR 3 0 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: C L _ <br />EMPLOYEE M CW <br />k <br />DATE: 0,5 - <br />✓ASSIGNED <br />ASSIGNED TO: <br />EMPLOYEE #: � <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: " 2 <br />Amount Paidc-) <br />Payment Date 3� S <br />Payment Type <br />Invoice # <br />Check # qs <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />S <br />