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SAN JOAQUIN#LINTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Typ Business or operty <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />S VICE REQUEST # <br />OWN / OPERATOR <br />�) <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />RC1 17 2005 <br />- <br />F <br />k;14 <br />SITE ADDRESS �] <br />—� r��Street Number <br />Direction <br />e C�' <br />HATH DEPARTMENT <br />Umi <br />O5 <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE M (f 37-3 <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />Fee Amount: 2:7 q, fro <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />Payment Date <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ah� Ah' <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />_ � kr=�- <br />�) <br />> EXT. <br />HOME or MAILING WDIDRESS � <br />;✓�101 <br />RC1 17 2005 <br />- <br />F <br />k;14 <br />/ J <br />CITY r <br />STATE <br />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 on this form. <br />I also certify that I have prepared this plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standarty, S ATE and F%DERAL 1 s. <br />APPLICANT'S SIGNATURE: DATE: ` 0.3'' <br />R <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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. <br />TYPE OF SERVICE REQUESTED: GQ}S ?— � F --Pr <br />YMEN-T <br />COMMENTS: <br />REC <br />RC1 17 2005 <br />SAN JOAQUiN COUNTY <br />HATH DEPARTMENT <br />ACCEPTED BY: d L -l. u &-I to <br />EMPLOYEE #: ?, Z <br />h7Gs <br />DATE: 16)I- <br />ASSIGNED TO: (��$ U <br />EMPLOYEE M (f 37-3 <br />DATE: 10 i 7 I/oS <br />Date Service Completed (if already completed): <br />SERVICE CODE: r 8 <br />P I E: 9 <br />Fee Amount: 2:7 q, fro <br />Amount Paid <br />Payment Date <br />Payment Type �� <br />Invoice # <br />Check # � (� � " <br />Received By: <br />