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V <br />SAN JOAQUIN*LINTY ENVIRONMENTAL HEALT * PARTMENT <br />SERVICE REQUEST <br />Pro rty <br />Type of Bu?7; <br />BUSINESS NAME �� <br />FACILITY ID # <br />HOME Or MAILING ADDRESS- %�, <br />SERVICE REQUEST # <br />CITY CL r (��TAT ZIP <br />2005. <br />Sq NCO JOAQUIN OOU 7y <br />OWNER / OP RATOR / <br />//�� / / <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: Q <br />SITE ADDRESS <br />ASSIGNED TO: f;-` <br />52y r ( <br />I ` -Street Number <br />Direction <br />SERVICE CODE: i <br />��' ` treet Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If ifferent from Site Address) <br />Lo'a4treet <br />Payment Type <br />V� <br />Street Number <br />Check # <br />Name <br />CITY <br />7� <br />Cl i r STATE ZIP 9q5—:9 �—: <br />PHONE #'I ExT. <br />0Z I <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME �� <br />PHONE Ext. <br />HOME Or MAILING ADDRESS- %�, <br />FAX# <br />CITY CL r (��TAT ZIP <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,11AATE ano FEDERAL laws. j <br />APPLICANT'S SIGNATURE: IJLL(L t6- DATE: I ^W� <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IS,J <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 environrnental/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: GAS f 2E/jZaGj) <br />PaY <br />COMMENTS: <br />ft Vcp <br />MAR 1 <br />2005. <br />Sq NCO JOAQUIN OOU 7y <br />1lEALTN pEPARNIIE rAL <br />hfP <br />ACCEPTED BY: <br />EMPLOYEE #: Q <br />DATE:�S- <br />ASSIGNED TO: f;-` <br />EMPLOYEE #: '� 3 Yo <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: i <br />P I E: �30 <br />4 <br />Fee Amount: �-7gV0 <br />Amount Paid <br />-®— <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />eceived By: � <br />EHD 48-02-025 SR FORM (Golden Rod <br />REVISED 11/17/2003 <br />