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NAN JOAQ COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br />SERVICE REQUEST <br />Type o usiness or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />S4 ® C-7 Lf.3 <br />OWNER/ OPERAT R <br />• <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Oq <br />EMPLOYEE #: () <br />SITE ADDRESS �\j/-�\� a �9 <br />Street Num er Direction i Street Name <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: 2�'"7 C) <br />Street Name <br />CITY <br />Date Service Completed (if already completed): <br />STATE ZIP <br />PHONE #'I ExT• <br />( ) <br />AP <br />P I E:.Z ©g <br />LAND USE APPLICATION # <br />[PHONE #2T <br />( ) <br />Amount Paid <br />BOS DISTRICT <br />LOCATION CODE <br />dONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Q h M� `� " - <br />� (1 CHECK If BILLING ADDRESS <br />BUSINESS NAME ` / <br />HOME or MAILING ADDRESS l� <br />CITY STATE ZIP r— <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, Standard , ,ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:- <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER U. OTHER AUTHORIZEDAGENT]C.�J <br />IfAPPGICANT is not the BILLING PARTY proof of authorization to sign is require 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: <br />PAYMENT <br />RECEIVED <br />JAN - 7 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />CL I UEIAe4 <br />EMPLOYEE #: () <br />DATE: //71/1 <br />ASSIGNED TO: <br />-A-( D u <br />EMPLOYEE #: 2�'"7 C) <br />DATE: //-7/// <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E:.Z ©g <br />Fee Amount <br />&6 ,L -V <br />Amount Paid <br />_ <br />Payment Date <br />Payment Type <br />1'�— <br />Invoice # <br />Check # Z ( <br />Receive By: <br />EHD 48-02-025 `S QR R <br />REVISED 11/17/2003 <br />