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SAN JOAQUW-OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CtAS -,-TA Fi <br />auLkl <br />v <br />L 53l <br />OWNER / OPERATOR -T-r—ScrL7 �� �`k6 <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />v S A ` t?.e-Eml4-0 LIA <br />HOME or MAILING ADDRESS <br />SITE ADDRESS <br />I <br />CITY <br />STATE C <br />q <br />Street Number <br />DirectignVL <br />t et Name <br />EMPLOYEE #: <br />Cit <br />i C <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />DATE: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />Qcq) taq _ sa S' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z ExT• <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />Y1 <br />auLkl <br />BUSINESS NAME r <br />PHONE <br />EXT• <br />HOME or MAILING ADDRESS <br />COUNTy <br />SA JO�Q UIN tJ1E <br />FAX # <br />CITY <br />STATE C <br />ZIP Q f ' , <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 <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 />APP)[,ICANT'S SIGNATURE:hl 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. <br />TYPE OF SERVICE REQUESTED: <br />�i <br />COMMENTS: a /Q j j , <br />auLkl <br />COUNTy <br />SA JO�Q UIN tJ1E <br />TSAL <br />TMEN�IR pEN <br />LT N EPAR <br />HEp <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: w ID <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: A <br />P / E: <br />Fee Amount: o <br />Amount Paid <br />�a� O <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # a 5 7 <br />Received By: 7 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod <br />