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14 0 <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIJ DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME / <br />PHONE F _ EXT. <br />HOME or MAIUNG ADDRESS �;` <br />l� <br />0VVdER / OPERA -WR _ <br />/1 h 1 <br />CHECK if BILLING ADDRESS CI <br />FACILITY NAME <br />SANJOAQUINEN <br />FtDEPARTMENT <br />H <br />SITE ADDRESS <br />Street Number <br />Direction <br />ACCEPTED BY: <br />��1 Wry% �Q�Stmet Name <br />EMPLOYEE #: /�J� <br />DATE: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />® <br />Street Number <br />3Freet Nam <br />CITY <br />ASSIGNED TO: <br />STATE <br />ZIP <br />2�-(J <br />EMPLOYEE #: <br />PHONE #t E-- <br />(.2' )(,� c� - 3-� <br />DATE: <br />APN S <br />LAND USE APPLICATION # <br />SERVICE CODE: <br />P,(HoNE #2 �• <br />6C6 ) ci <br />P I E: �C) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />v <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME / <br />PHONE F _ EXT. <br />HOME or MAIUNG ADDRESS �;` <br />l� <br />FAX # <br />(er) <br />CITY % <br />0L STATE <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, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: C� DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTET , <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 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. —.,/r, AFNT <br />1 /- <br />TYPE OF SERVICE REQUESTED: L/ Y2 <br />tV — - <br />REC <br />COMMENTS: <br />AN 2 4 2005 <br />JWY <br />SANJOAQUINEN <br />FtDEPARTMENT <br />H <br />H <br />ACCEPTED BY: <br />EMPLOYEE #: /�J� <br />DATE: <br />��- J <br />ASSIGNED TO: <br />-f -a <br />2�-(J <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already com leted : <br />SERVICE CODE: <br />�> <br />P I E: �C) <br />Fee Amount: <br />�� �/ ' <br />Amount Paid <br />'Z �c� �� L; <br />PaymentlDate Z o <br />Payment Type <br />Invoice # <br />Check # 3 <br />Re eive By: <br />EHD SR FORM (Golden Rod) <br />REVISEDSED 11/1 11!17/2003 <br />D V <br />