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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Type of Business or Property <br />FACILITY ID # <br />G <br />`[ l/ <br />IL6BUSINESS <br />REQUEST # <br />s�- <br />5c94,Q b a <br />PHONE# EXT. <br />[----SERVICE <br />OWNER/ OPERATOR <br />abj-- <br />CHECK if BILLING 13 <br />i <br />FAx# <br />(,Av°r) zw--I <br />ADDRESS <br />FACILITY NAME <br />Invoice # <br />Check # <br />SITE ADDRESSElf <br />fC G( `�C� <br />5-7 4 <br />Street Number <br />Direction <br />Street Name <br />i Code <br />HOME Or (NAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #'l EXT. <br />( ) <br />PN* <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE 4PA.UEST4,12 <br />REQUESTOR <br />CHECK if BILLING <br />G <br />`[ l/ <br />IL6BUSINESS <br />ADDRESS <br />NAME <br />ASSIGNED TO: <br />PHONE# EXT. <br />DATE: <br />Date Service Completed (if already completed): <br />abj-- <br />HOME or MAILING ADDRESS <br />tato W• e 37-3 <br />Fee Amount: <br />FAx# <br />(,Av°r) zw--I <br />CITY <br />STATE/ n zip 9 yds® <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 DP.PARTML NT 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 1 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 FGDGRAI, laws. <br />APPLIC'ANT'S SIGNATURF2 DATE: <br />IF <br />E: ' ` <br />PROPER'1'V/BUSINFSSOWNER❑ 011FRA-rr�IJ+ <br />OR/MANAGER ❑ 0.1-liPRAEJI�IiORIZE'.DA(.EN�L� OPQCM <br />/f 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 ENVIRONMEN'I'At, HEAL,TII DEPART'MF.N'f 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 />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />