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SAN JOAQU*OUNTYr 1ENV40NMENTAL REAL TI PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />+ <br />oo Nk1> <br />Obd �% <br />Gip <br />OWNER / OPERAT <br />! <br />CITY <br />CHECK If BILLING ADDRESS to <br />ASSIGNED TO: <br />� la <br />FACILITY NAME ,,+ <br />SITE ADDRESS <br />880 <br />lJ V <br />Fee Amount: OV <br />Amount Paid -;7 <br />� f1 <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />Ci <br />iOC/o ev <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />o <br />PHONE #2 <br />(i ) 8�a-577 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1 <br />CHECK if BILLING ADDRESS ❑ <br />16t`&on <br />BUSINESS NAME <br />�Z <br />�t n Tnrr. <br />NNE # ExT. <br />- <br />HOME or MAILING A ES <br />ACCEPTED BY: <br />FAX # <br />) 17 -a5 46 <br />CITY <br />�y �.1 _ STATE O-Azip / <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 />APPLICANT'S SIGNATURE: r DATE: to- ®� <br />PROPERTY/BUSINESS OWNER OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENTL.VPAVIMW I <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required ditle <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 availabPArt PF me time it is <br />provided to me or my representative. or-r1--.1VE-Q <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: OV <br />Amount Paid -;7 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 1�51 8�q— <br />Re eive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />