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SAN JOAQUI)OUNTY ENVIRONMENTAL HEALT�EPARTMENT <br />SERVICE REQUEST <br />,Type of Business or Pro rty <br />CHECK If BILLING ADDRESS <br />11, > <br />FACILITY ID # <br />5 <br />am), <br />SERVICE REQUEST # <br />15&V q3L&:,- <br />OWNER/ ERATOR .� <br />t <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE M <br />t <br />SITE ADD R S� <br />1 Street Number <br />Direction <br />J <br />I' w" t Name <br />SERVICE CODE: <br />S <br />i <br />i Cod <br />HOME or MAILIN DDRESS (If Different from Si <br />f <br />Address) ��/ <br />Street Number <br />&1� <br />L21-,/ d�� <br />CITY <br />NNWLi <br />i <br />STA E ZIPr <br />4 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 % ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR " Lu <br />CHECK If BILLING ADDRESS <br />11, > <br />BUSINESS NAME <br />am), <br />PHONE Exr. <br />HOME or MAILING AD ESSFAX# <br />00 <br />CITY <br />STATE <br />EMPLOYEE M <br />t <br />, , . - <br />BILLING ACKNO L DGEMENT: 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. Q� <br />APPLICANT'S SIGNATURE: @ DATE: V� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLiCANT is not the BILLING PARTY, proof of authorization to sign is required Title CC�� <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: l -f- " <br />11, <br />P <br />COMMENTS: <br />t-fEEEII/ED <br />AUG 2 2 2005 <br />SAN JOAQUIN CENVIRONOUWTY <br />HEALTH DEP ENTAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 22 D <br />ASSIGNED TO: Ca e( <br />EMPLOYEE M <br />t <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />S <br />P I E: Q$` <br />Fee Amount: <br />Amount Paid <br />"' <br />Payment Date `6 aZ f)�✓ <br />Payment Type ✓ <br />Invoice # -r . <br />Check # O�s <br />Received By: <br />EHD 48-02-025 -n „ <br />REVISED 11/17/2003 <br />