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SAN .TOAQU'*'OUNTY ENVIRONMENTAL HEALTH10, ENT <br />SERVICE REQUEST <br />Type of Business or Property <br />y <br />BUSINESS NAME <br />FACILITY IID # <br />!&^ <br />SERVICE REQUEST <br />C/ l� <br />OWNER /OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME —C 6,v— 0 <br />. <br />E AD_DREES� <br />`� ' C� S t N r <br />Dfren <br />Street Name �� <br />Ci <br />i r t(j <br />ZI Code <br />HOME Or AILING ADDRESS (If Different from Site Address �• _ ��,� p C , <br />St et Number Str et Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />(C�k() a&.� -S % <br />APN # <br />A qbS <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />Payment Type <br />BOS DISTRICT ., <br />LOCA ON ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Exr' <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE 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 <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 rnh t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an FEDE L laws. <br />APPLICANT'S SIGNATURE: �--- .^--^ DATE: � <br />PROPERTY / BUSINESS OWNER [3 OPERATOR / M AGER ❑ 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. PAYMENT <br />TYPE OF SERVICE REQUESTED: 1 % ('Ww <br />RECEIVED <br />COMMENTS: <br />JAN 0 7 201 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: l C <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: J <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ©1p <br />P I E: 2 <br />Fee Amount: } t� <br />Amount Paid <br />3O _ . <br />Payment Date I —71 s <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />