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SAN JOAQU0OUNTY ENVIRONMENTAL HEALT*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />,U1� <br />COUP1it <br />BUSINESS NAME / / <br />t ,[ �/ <br />SPN SOP pNMEN-(A�Nj <br />PHONE# c EXT. <br />C F� <br />OWNER /OPERATOR <br />/ <br />� �`�P <br />CHECK if BILLING ADDRESS <br />l/ <br />Q <br />GSC I f •.Q 1�'fJ C.(if� <br />ASSIGNED TO: Va\/t <br />FACILITY NAME <br />,2,. l0c <br />DATE: <br />-OI <br />SITE ADDRESS (S <br />tom% <br />C-� �c <br />S(c'C�C�I� <br />��2��• <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Received By: �( G <br />gF5 1—tC,v0 <br />�S� \�� I Street Number <br />Street Name <br />CITY J� j � � <br />K <br />STATE � /� ZIP �+S-. 2O <br />( io <br />PHONE #i <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRES , <br />COMMENTS: <br />,U1� <br />COUP1it <br />BUSINESS NAME / / <br />t ,[ �/ <br />SPN SOP pNMEN-(A�Nj <br />PHONE# c EXT. <br />C F� <br />HOME or MAILING ADDRESS <br />N��TH n�pP�SM <br />ACCEPTED BY: L/ <br />FAX # <br />('7a� ) -?yg-- - 071—S_ <br />CITYS4�c( � C <br />ASSIGNED TO: Va\/t <br />STATE 09 ZIP C'r ZQ / <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 or <br />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 an ERALlaws. <br />APPLICANT'S SIGNATURE: DATE: jo �� Ao � <br />PROPERTY / BUSINESS OWNER PERATOR / MANAGER OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING -PARTY, proo 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 tl a same time it is <br />provided to me or my representative. 'P <br />TYPE OF SERVICE REQUESTED: <br />R <br />COMMENTS: <br />,U1� <br />COUP1it <br />SPN SOP pNMEN-(A�Nj <br />N��TH n�pP�SM <br />ACCEPTED BY: L/ <br />EMPLOYEE #: <br />DATE: &&14 <br />ASSIGNED TO: Va\/t <br />EMPLOYEE #: <br />/ it <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( <br />PIE: �Pjf <br />Fee Amount: " <br />Amount Paid <br />�C� <br />Payment Date <br />Payment Type V �S <br />Invoice # <br />C -Retic'# U L�✓1 ✓1 <br />Received By: �( G <br />EHD 48-02-025 C-XA*- SR FORM (Golden Rod) <br />REVISED 11/17/2003 0l 77C <br />