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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Typ of Business or Property <br />>f \or <br />V <br />CHECK If BILLING ADDR S <br />FACILITY ID # <br />� L <br />SERVICE REQUEST # <br />C ON{ZI 3 . <br />WNE / OPERATOR% <br />la rve\ 7: n <br />ot) Z <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME <br />' 1 <br />I <br />CITY <br />SiT ADDRE S <br />Street Number <br />STATE ZIP <br />Direction <br />ate/' <br />�— `�1 <br />trreeet NameZic <br />SERVICE CODE: / <br />J <br />qD4 <br />CodJe <br />SS (IIf✓Dyiff <br />Homvgr <br />fr Si ddres� <br />Amount Pa' <br />�� <br />AINGADD <br />44 .1v1 <br />d <br />Street Number <br />Street Name <br />CITY�'% <br />Check # Sl / <br />Rec ived By: <br />TATE ZZI <br />iCA <br />66 <br />PHONE #1 <br />EXT, <br />APN # <br />LAND USE APPLICATION # <br />RHONE" 4 <br />EXT6 <br />LOICODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR�� <br />CHECK If BILLING ADDR S <br />BUSINESS NAME � <br />� L <br />p Exr. <br />HOME Or MAILING ADDRESS <br />� <br />EMPLOYEE #: <br />I <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 <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 ap lication and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br />ra; <br />. <br />��'OGNATURE: DATE: 002(0), <br />PROPERTY/ BU OWNER❑ OPERATOR/ MANAGER ❑ THER AUTHORIZED AGENT I <br />JUN U MPL[CANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br />AUT O RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />4ereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />i�TV eiukrTWAN 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: Vet C/0 S 5�V✓1 aNG' �"t(tct;f 1?P1 B IS novel rf/s-�e G{1sC hcs�: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />"e <br />COMMENTS: to ('(atC- the We3S <br />f16I0 C')eLk (SILOc,?1,741) <br />pG1(/� CcIVl b J'r Q <br />/ <br />f fei hon , per 11/%'o ZOGO leli / tai vJl1S�t I?GCl <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: J'� <br />EMPLOYEE #: <br />DATE: 4 oa a Ja D <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />J <br />P I E: `�vZ poZ <br />Fee Amount: <br />Amount Pa' <br />�� <br />Payment Date <br />2�!—EJ <br />Payment Type(2 <br />Invoice # <br />Check # Sl / <br />Rec ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />