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SAN JOAQUIN <br />(:OUNTY ENVIRONMENTAL HEALTH DEPA 'PMENT <br />SERVICE REQUEST <br />FACILITY ID # SERVICE REQUEST # <br />Type of Business or Property � ry rl 11 <br />Serie 0© I� Q �� <br />OWNER/ <br />FACILITY <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />(HSI <br />PHONE #2 <br />( 1 <br />REQUESTOR <br />BUSINESS NAME "0/-A <br />EV. I APN # <br />Exr. <br />CONTRACTOR / SERVICE <br />HOME or MAILING ADDRESS''O <br />© <br />CITY �i"i I [I (a 1 t �••J� oJj <br />CHECK If B(LLINO ADDRESSCI <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT II LOCATION CODE <br />CHECK If BILLING ADDRESS <br />EXT. <br />STATE ZIP <br />� Uvv�iv <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 pplication that the work t0 be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, T TE d F ERAL laws. <br />DATE: <br />APPLICANT'S SIGNATURE: <br />' <br />PROPERTYIBusrNESSOVYNER13 OPE TO ER ❑ OTHER AUTHORIZEDAGENT� <br />If APPLICANT is not the B!L N PA pr of of authorization to sign is required Title <br />AT TO LEA E INF A IO : When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release o 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 />PAYME;NTl <br />TYPE OF SERVICE REQUESTED: <br />COMMENT,i.," rex-OKA <br />JUL 3 <br />io a\LL� 1 S� jOAQUIN COUP" <br />ENTM DEPARTME <br />ACCEPTED BY: 0 L ( V -Et <br />ASSIGNED TO: lJ <br />Date Service Completed (if already completed): <br />Fee Amount: �L( ':Payment Type � Invoice # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />EMPLOYEE M O 3 Z( <br />DATE: ^l _Z d f-0 <br />EMPLOYEE #: Gj c/(fe <br />DATE: 30 10 <br />SERVICE CODE: t g <br />P i : ,2-3 O 9 <br />3 <br />Payment Date <br />30 ( v <br />shaK# CO) u S y 5 <br />I Received By: >s <br />C,o.n <br />SR FORM (Golden Rod) <br />