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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />A DDRESS <br />CHECK ti BILL NG LIN <br />BUSINESS NAME <br />OWNER If OPERATOR <br />Ff" Alt w A <br />CHECK If BILLING ADDRESS,—V <br />FACILITY NAME <br />44" <br />RESS <br />HOME or MAKING ADD.— <br />SITE ADDRESS % <br />EMPLOYEE <br />CAW <br />tt,�L. <br />cylp 1'6'*b D�, <br />01 Czi .),11fo <br />tree(N..b., <br />D61g. <br />CITY <br />Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />- <br />Invoice # <br />NELJ <br />Check # <br />Street Number <br />SILeet Name <br />CITY <br />STATE zip <br />NOV <br />PHONE #1 EXT. APN # <br />J <br />LAND USE APPLICATION # <br />zo 0 <br />PHONE #2 EXT. <br />BOS DISTRICT LOCATION <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />-'b <br />w� <br />Stu? 9 <br />4�v LkZ— 03A I a a <br />A DDRESS <br />CHECK ti BILL NG LIN <br />BUSINESS NAME <br />EMPLOYEE #: <br />DATE' <br />ASSIGNED TO: <br />RESS <br />HOME or MAKING ADD.— <br />EMPLOYEE <br />DATES <br />Date Service Completed (if already completed): <br />cylp 1'6'*b D�, <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />CITY <br />STATE <br />zip 07 <br />offl <br />i2m <br />BILLING ACKNOWLEDGEMENT: 1, 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 identifi on this form. <br />I also certify that I have prepared this a Iication Jalhat the work to be performed will be done in accordance with all SAN JOAQUIN <br />pp' <br />s, ST I <br />COUNTY Ordinance Codes, Standard AT" d F ERAL laws <br />APPLICANT'S SIGNATURE: DATE: <br />N—le AN ER ❑ OTHER AUTHORIZED AGENT 11 <br />PROPERTY /BUSINESS OWNER 11 OPERATOR , -AA�e-tf IAANA40e� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required %J I I Me #– <br />AUTHORIZATION TO RELEASE INFQRMATION When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. '"LdVCUU_ _ 1113H <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />-'b <br />w� <br />Stu? 9 <br />4�v LkZ— 03A I a a <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE' <br />ASSIGNED TO: <br />EMPLOYEE <br />DATES <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />I Amount Paid :[Eym:e:n:t:Date <br />Payment Type <br />- <br />Invoice # <br />Check # <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />