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✓"'WIift <br />SAN JOAQU*OUNTY ENVIRONMENTAL HEALTISPARTMENT OCT 2 7 2016 <br />SERVICE REQUEST <br />ENVIRO ' 1N <br />R16ERVIC S <br />T e of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />myP <br />SERVICE <br />OWNER 10 RATOR <br />HOME or MAI G ADDRESS <br />v <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />STATE ZIP � Sr7U <br />SIT ADDRESS <br />> Street Number <br />Direction <br />jd ii11 �/� <br />�1 C Street Name <br />�C Qum <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />ACCEPTED BY: <br />Street Name <br />CITY <br />DATE: <br />STATE ZIP <br />PHONE #1 ExT. <br />( ) <br />APN # <br />a <br />4? r Q <br />'1 V <br />LAND USE APPLICATION # <br />PHONE #Z ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�I i r� <br />CHECK If BILLING ADDRESS ro <br />BUSINESS NAME <br />myP <br />v� <br />PHONE# EXT. <br />1 2[7� i <br />HOME or MAI G ADDRESS <br />v <br />FAX # <br />( ) <br />CITY ' y, <br />STATE ZIP � Sr7U <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project spe NVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my bus' ess as i ntified on this form. <br />I also certify that I have prepared this a plication a d that the work to be ormed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar TATE and ERAL <br />APPLICANT'S SIG' NA URE: DATES: ) to I 10 <br />PROPERTY / BUSINESS OWNER TOR / AGER ❑ OTHER AUTHORIZED AGENT�W� ) <br />If APPLICANT is not th LING PARTY proof of authorization to sign is require Title <br />AUTHORIZATION TO RELEAS INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authoriz 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:FNS <br />NOS 0 <br />uH�o, ?O�g <br />H6�� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: )CI K <br />P! E: <br />Fee Amount: �IjD <br />Amount Paid-"A'�� <br />7 v� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # k5_73;7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />