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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST r <br />1qWType Busji^ne�� or Prop'rt' <br />UVn�6m <br />FACILITY ID # <br />y!?q <br />BUSINESS NAME <br />SERVICE REQUEST # <br />Sl <br />OWNER I OPERATOR <br />n <br />I 1 I / pl ✓i Q /1� <br />W lll��- til 1 w t l <br />CHECK if BILLING ADDRESS E] <br />FACILITY NAME <br />JUL 6 2007 <br />s <br />( ) / <br />SITE ADDRESS/ „ �� j /, • <br />Street Nu er Di ection <br />e ' /U `✓ Ci Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />4� <br />�- — - - <br />EMPLOYEE #: <br />STATE ZIP ,. <br />— <br />PHQNE t) <br />—t�-7 <br />EXT- <br />94�-iV <br />APN # <br />, o.6Q, <br />LAND USE APPLICATION # <br />PHOq#� <br />EXT <br />SERVICE CODE: l <br />BOS DISTRICTOCATION <br />LCODE <br />n CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE / -7 EXT' <br />HOME or MAILING ADDRS' <br />COMMENTS: <br />Fax <br />JUL 6 2007 <br />s <br />( ) / <br />CITY <br />STATE ZIP <br />BILLING ACKNOWLEDGEM"IAT: 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 applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <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. PAYM EN ( <br />EHD 48-02-025 ;SR FORIN (Golden Rod) <br />REVISED 11/17/2003 <br />RECEIVED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JUL 6 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: / �r� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: l <br />P 1 E: <br />Fee Amount: <br />Amount Paid S w <br />Payment Date ! b <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 ;SR FORIN (Golden Rod) <br />REVISED 11/17/2003 <br />