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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST ib <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAMEU19 �8 ��"'_ <br />SERVICE REQUEST # <br />® <br />HOME or MAILING ADDRESS Tom/ j'� <br />1 Z <br />FAX # <br />CITY <br />OWNER / OPERATOR <br />DATE: � Ee 06 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Fee Amount: ' �� <br />Amount Paid <br />SITE ADDRESS <br />2 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />f <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />Ll <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />O • R_ <br />REQUESTORk p (�y <br />�1v1 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEU19 �8 ��"'_ <br />PHONE# ) y� EXT. <br />HOME or MAILING ADDRESS Tom/ j'� <br />EMPLOYEE #: f <br />FAX # <br />CITY <br />STATE ( 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 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 SIGNATUREH DATE: Iy z.� <br />PROPERTY / BUSIINESS OWNER W OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ (A) <br />IfAPPZICANT is not the BiLmNGPARTY, 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: <br />COMMENTS: <br />ACCEPTED BY: C)U 11 I <br />EMPLOYEE #: f <br />DATE: <br />ASSIGNED TO: V p <br />EMPLOYEE M V j % --7! <br />DATE: � Ee 06 <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 />