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SAN JOAQUIN I-OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />0 SERVICE REQUEST is <br />Type of Business or Property <br />LAI <br />BUSINESS NAME � � <br />\ <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CITY STATE ZIP G <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME r <br />EMPLOYEE #: <br />DATE: <br />SITE ADDRESS <br />Street Number <br />Direction <br />DATE: <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Amount Paid <br />STATE ZIP <br />PHONE #1 EXT. <br />Payment Type <br />APN # <br />Invoice # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />� CHECK If BILLING ADDRESS <br />C'Vy� /// <br />BUSINESS NAME � � <br />\ <br />PHONEP _ EXT. <br />HOME or MAILING ADDRESS 2 <br />(� <br />JU r <br />� <br />p� <br />(O i lU� <br />CITY STATE ZIP G <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 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: DATE: q <br />-gyp y� r <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If 4PPLICANT is not the BILLING PARTY, proof of authorization to sign is require 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 environmentaUsite 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 />Y1ENT <br />COMMENTS: a y� tc`t--/3 \ <br />hcvtaou- <br />—{S� <br />O eJ "j - <br />&Qk6 ok�i3 bUcrlct 5lcc:ve.J CYl Ql k <br />BEG <br />SEP - 9 Zoos <br />NN <br />SAN �� �oNMENS ENT <br />EALTN pEPAR1M <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:LI `-> C <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />G <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 1 Z(o k <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />