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SAN JOAQUI*UNTY ENVIRONMENTAL REALT*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />ERVICE REQUEST # <br />OWNER / OPERATOR <br />�V �' <br />CHECK if BILLING ADDRESS <br />FACILITY NAM <br />6DDi�� Ea' <br />EMPLOYEE #: <br />SITE ADDRESS <br />' O J 2 Street Number <br />Direction <br />SSS St eet Name <br />STATE,,,l ZIP q- yo <br />V CI <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Fee Amount: Z/ Gh <br />STATE ZIP <br />PHONE #1 Ex. <br />( ) <br />S <br />APN # <br />I invoice # <br />LAND USE APPLICATION # <br />PHONE#2 Evr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR .j <br />CHECK if BILLING ADDRESS ID <br />BUSINESS NAME <br />/ <br />v—©tel <br />�V �' <br />PHONE# E'R' <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: <br />Fax # <br />CITY /I <br />STATE,,,l ZIP q- yo <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 projector <br />activity will be billed to me or my business as identified on this fort. <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 apd-F ERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 7 m <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENF :- <br />IfAPPLicANTisnottheBiLLiNGPAR7Tproof ofauthorization to sign is required rine <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 />COLO <br />_ <br />COMMENTS: V �� I �l "�'00 <br />�V �' <br />sta" got: ��'•'_ <br />H <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: /S <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Co ted (if already Completed): <br />SERVICE CODE:13-2 Z <br />PIE: 02— <br />Fee Amount: Z/ Gh <br />Amount Paid ` <br />Payment Date <br />S <br />Payment Type L,-- <br />I invoice # <br />Check # 3 1�0 (o <br />Received By: �� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />