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A <br />SAN JOAQUIOUNTY ENVIRONMENTAL HEALTHSARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />VI L-- <br />RECEIVED <br />FACILITY ID # <br />PHO E# ExT. <br />SERVICE REQUEST # <br />c <br />6 <br />� <br />OWNER / OPERATOR <br />ACCEPTED BY:/� <br />WiV ' <br />( ) <br />CITY STATE ZIP <br />ASSIGNED TO: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />�. <br />SERVICE CODE: Z COW <br />P / E: <br />r Iva <br />Fee Amount: <br />SITE ADDRESS <br />Payment Date <br />` ��GStrt <br />Invoice # <br />GA5 <br />Received By: _ <br />ZfzStreet Number <br />Direction <br />Names <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />Rg4WESTOR,o <br />CHECK If BILLING ADDRESS <br />VI L-- <br />RECEIVED <br />B ESS NA <br />PHO E# ExT. <br />'' <br />SAN JOAQUIN COUNT( <br />ENVIRONMENTAL <br />HOME or MAILI DDRESSFAx <br />HEALTH DEPARTMENT <br />ACCEPTED BY:/� <br />WiV ' <br />( ) <br />CITY STATE ZIP <br />ASSIGNED TO: <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, ST TE a F E laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER [3 PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPL/CANT 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. AN41 A -I <br />R �- <br />TYPE OF SERVICE REQUESTED: <br />TYPE <br />VI L-- <br />RECEIVED <br />COMMENTS: <br />MAY 2 2 2009 <br />SAN JOAQUIN COUNT( <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:/� <br />WiV ' <br />EMPLOYEE #: <br />DATE: 7_ <br />!� <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: Z COW <br />P / E: <br />r Iva <br />Fee Amount: <br />Amount Paid 1 5 <br />Payment Date <br />Payment Type 1/ <br />Invoice # <br />Check # t4 2_ S <br />Received By: _ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />