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SAN JOAQUIN#UNTY ENVIRONMENTAL HEALT�PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />cFi Nr <br />COMMENTS: <br />FACILITY ID # <br />ACCEPTED BY: dr, L i �� <br />SERVICE REQUEST # <br />+% <br />DATE: C� (j <br />ASSIGNED TO: �L(V E Ai 0-0 <br />70` <br />EMPLOYEE #: <br />SCoa S �-- -? 0 <br />OWNER / OPERATOR <br />SERVICE CODE:C? <br />CHECK If BILLING ADDRESS <br />Fee Amount: - <br />Amount Paid <br />O <br />Payment Date f O D <br />Payment Type <br />Invoice # - <br />Check # 5 <br />FACILITY NAME (a <br />r, <br />t <br />SITE ADDRESS A-1 <br />i <br />�ah�l►� P'd <br />V <br />�,}h�� <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />(2601 2t,&6 <br />EXT. <br />APN # <br />CS &,_7/ <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />ExT. <br />BOS DISTRICT !["CATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />�- cru <br />BUSINESS NAME PHONE 'qol jXT' <br />HOME or MAILING ADDRES.S FAX # <br />( q1) 40- CD <br />CITYSTATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnortzea agent oz 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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: [j DATE: LL '( e \ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT 6 l //�� t nia T 1 �f``'' u C L_ <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 SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PA V., _ <br />TYPE OF SERVICE REQUESTED: f S ! -I-,V- <br />cFi Nr <br />COMMENTS: <br />MAR <br />sqN Joy 1 2449 <br />yEACTV/q N /V cCV <br />yoFpq� New <br />ACCEPTED BY: dr, L i �� <br />EMPLOYEE #: U <br />DATE: C� (j <br />ASSIGNED TO: �L(V E Ai 0-0 <br />EMPLOYEE #: <br />DATE: r C' <br />Date Service Completed (V already completed): <br />SERVICE CODE:C? <br />P i E:_3 (> <br />Fee Amount: - <br />Amount Paid <br />l5 BO <br />Payment Date f O D <br />Payment Type <br />Invoice # - <br />Check # 5 <br />Receive By: <br />EHD 48-02-025 ;',SR FORM {GDlden.Rod) <br />REVISED 11/17/2003 <br />