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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERV ,CE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING Ap(�' RES <br />D J^ <br />FAx # <br />( ) <br />(,0 <br />ILPD4 <br />OWNER/ OPE T <br />er � <br />l <br />ACCEPTED BY: y, Y YE <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />t <br />ASSIGNED TO: <br />!� Gn <br />DATE: <br />Date Service Completed (if already mpieted): <br />SITE ADDRESS f o, <br />Mo <br />4-0.?LQ <br />�C'ty/ZI <br />Amount Paid <br />/5;2 , <br />Nber <br />5treetum <br />Dlrectlo <br />Street Name <br />1 -11 <br />Check # <br />Received By: <br />Cotle <br />HOME or MAILING ADORE S (If Different rom Site Address) <br />q4' 2 <br />rL 1d6 -Y' w (1 G. <br />Street Number <br />treat Name <br />CITY <br />STATE ZIP <br />L Ove <br />PHONE EZT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR``�� <br />#(.e ' - CHECK It BILLING ADDRESS <br />`� CC <br />BUSINESS NAME <br />C Lg �11 <br />PHONE # EXT <br />HOME or MAILING Ap(�' RES <br />D J^ <br />FAx # <br />( ) <br />CITY Lo I i STATE 64 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 <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 and that the work to be petformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE:��� <br />PROPERTY/BUSINESS OWNER PERATOR/MANAGER❑ OTHER AUTHORIZED AGENT <br />/fAPPLICAN 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 available anol the Same time It IS <br />a`_ I <br />provided to me or my representative, ')UPp,, <br />TYPE OF SERVICE REQUESTED: <br />g/p/ <br />COMMENTS: Nuc0c UWA&1 <br />,t <br />Ap/ <br />20L <br />FNVIyOIV C <br />HSEAANCTT <br />�20 <br />POgRy <br />ACCEPTED BY: y, Y YE <br />EMPLOYEE #: <br />DATE: 01 -04 - <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already mpieted): <br />,L <br />SERVICE CODE: / } <br />PIE:') -L <br />Fee Amount: <br />Amount Paid <br />/5;2 , <br />Payment Date ,a 2,20 <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 />