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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST lb <br />Type of B iness or Pro erty A <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING AD RESS <br />SERVICE REQUEST # <br />—6�CITY ` �, r STATE ZIP <br />AUG 2 3 <br />OWNER / ERATOR <br />2007 <br />i <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS CIt1 O h J:1 <br />�n / f) <br />`'�)`Ij <br />Street Number Direction <br />St et me <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />DATE: <br />ASSIGNED TO: <br />7 <br />Street Number <br />DATE: <br />St eet Na re s <br />CITY <br />SERVICE CODE: <br />TATE ZIP 53 <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />.Date �3 (J <br />PHO E # EXT. <br />(' CI 79--11 01F2. <br />Invoice # <br />BOS DISTRICT :�Z]Mrd <br />I N CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHYNE i ExT. <br />HOME or MAILING AD RESS <br />FAx # <br />—6�CITY ` �, r 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 or <br />activity will be billed to me or my business as identified `this form. <br />I also certify that I have prepared this application an at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F DE laws. <br />APPLICANT'S SIGNATURE: f'Z DAT <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT�Zll <br />IfAPPLiCANT 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. <br />TYPE OF SERVICE REQUESTED: <br />SAY <br />COMMENTS: <br />l'EI1/ED <br />AUG 2 3 <br />2007 <br />Sq NVOA I N CO LINTY <br />FIEALTH DE ARNTgL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />00- <br />P I E: <br />Fee Amount: Z Va <br />Amount PaidPaymen <br />.Date �3 (J <br />Payment Type <br />Invoice # <br />Check # `ZA 1'—Z <br />Received By: � <br />EHD 48-02-025 ;SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />