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SAN JOAQUIr' —OUNTY ENVIRONMENTAL HEALTN r)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID #F5i11r,--11-)cD <br />ERVICE REQUEST # <br />V)v i�� QF -MNL <br />FAX # <br />Sc) -3C3 <br />OWNER / OPERATOR <br />^ � n <br />CHECK If BILLING ADDRESS ❑ <br />ENVIRONMFENTAL <br />HEATH DEPARTMENT <br />FACILITY NAME <br />EMPLOYEE #: <br />SITE ADDRESS 1 <br />ASSIGNED TO: �cC �y, <br />�1 <br />J� <br />1F -y– <br />Iylhc <br />I '\ � T <br />�7j �6 , <br />Street Numbe� <br />Direction <br />Fee Amount: d t) <br />S reed Name <br />C <br />Zio Code <br />HOME or MAILING ADDRESS(If Different from Site Address) <br />Invoice # <br />Check # <br />' Im <br />Street Number <br />Street Name <br />CINw <br />STATE ZIP <br />`` k-' C <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />Qcci! <br />23So �S <br />PHONE #2 EXT.BOS <br />DISTRICT <br />os- <br />LOCATION DE <br />v <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />I3ILLING ACKNOWLEDGEMENT: 1, 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 ; <br />COUNTY Ordinance: Codes, Stan( awls, and IF, I 1 <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER ❑ OPEf6T0R / NIANXGER ❑ <br />!f APPLICANT is not the BILLING PARTY, <br />to be performed will be done in accordance with all SAN JOAQUIN <br />DATE: 2--q —No <br />/ OTHER AUTHORIZED AGENT ❑ <br />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 />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />TYPE OF SERVICE REQUESTED: <br />E VED <br />COMMENTS: � <br />FEB _ 9 2013 <br />SAN JOAQUIN COUNTY <br />ENVIRONMFENTAL <br />HEATH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE' c <br />ASSIGNED TO: �cC �y, <br />EMPLOYEE #: / C -'y <br />DATE: <br />Date Service omp eted (If alreR4competed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: d t) <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: jam.,? 7`r <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />