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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />b0 <br />SERVICE REQUEST # <br />OWNER/ OPERATOR ` <br />,(--f 1v <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ir,n <br />i ,\^ <br />FAx# <br />(UgFLO--a l �- <br />SITE ADDRESS San S'ux `` ,,v jSCJ( n ,i <br />Street Number DirectionJ Street Name city Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />DATE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR-ej <br />a <br />CHECK If BILLING ADDRESS <br />BUSINESS <br />� Y`c. <br />EXT, <br />PHONE # �Fu 1 <br />('Uol) <br />HOME or MAILING ADDRESS <br />P-0- <br />� wln/�c t4,, . i u...,1� <br />FAx# <br />(UgFLO--a l �- <br />CITY I I\ /+L p <br />STATEC),3— ZIP QSN <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, STASE and F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: v l <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANA E ❑ OTHER AUTHORIZED AGENT Il Y V V <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 availabl�ett\the same time it is <br />provided to me or my representative. pP���Q <br />TYPE OF SERVICE REQUESTED: <br />QCl <br />Cor tz Tf° wt <br />con +_ � <br />/YWI <br />•� � <br />� wln/�c t4,, . i u...,1� <br />44 PN N <br />PaV�N <br />P ixA Wk � P'-�MENS <br />501 <br />Nom' <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />P I E: yJ� <br />Fee Amount: Z <br />Amount Paid <br />�+ v� <br />Payment Date <br />Payment Type I j' <br />Invoice # <br />Check # s� <br />Received By: u� <br />EHD 48-02-025 " ,SR FARM "(Golden Rod) <br />REVISED 11/17/2003 <br />