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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 />BUSINESS NAME �r 1 � " <br />FACILITY ID # <br />SERVICE REQUEST # <br />Lobb r (e- <br />FAX# <br />Dog AAi� <br />OWNER/OPERATOR <br />, <br />CHECK if BILLING ADDRESS <br />1\i <br />EMPLOYEE #: <br />DATE: 9V;X1 2 3 <br />— <br />ASSIGNED TO: V'N 6ol I� ! * <br />EMPLOYEE #: <br />DATE: <br />FACILITY NAME <br />SERVICE CODE: S2 <br />P I E: <br />SITE ADDRESS <br />I <br />Payment Date g 2a 2 0 <br />Street Number <br />Direction <br />Payment Type <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />ire Address) <br />� �� <br />-I Id <br />Street Number <br />StreetName <br />CITY I <br />$T T <br />5 '45 <br />(i� <br />4 O 6 <br />r1 <br />J <br />PHONE#t <br />EXT. <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />M650441 3 41 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 41 U rn t 2 ; <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME �r 1 � " <br />P NE# EXT' <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY <br />STATE ZIP <br />BILLING 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 <br />or activity will be billed to me or my business as identified on this fonn. <br />1 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 and FEDERAL taws.�7 �f <br />"APPLICANT'S SIGNAT rDATE: / C U / `� <br />PROPERTY/ BUSINESS OWNERLC OPERATOR/ MANAGER 13 OTHER A U`rHoFuzED AGENT 11 <br />/f APPLICANT is not the BILL/NG PARTY proof of authorization t0 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 />TYPE OF SERVICE REQUESTED: <br />--rec AY <br />C1' <br />COMMENTS: <br />C��I , <br />AUG Z Q c.0 <br />ory�, <br />EU20 <br />70%f8 O <br />ACCEPTED BY: wm �✓ <br />EMPLOYEE #: <br />DATE: 9V;X1 2 3 <br />— <br />ASSIGNED TO: V'N 6ol I� ! * <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S2 <br />P I E: <br />Fee Amount: k�5z <br />Amount Paid <br />Payment Date g 2a 2 0 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />M <br />EHD 4SR FORM (Golden Rot , <br />REVISEDED 1111 tt/17/2003 � o '\ �I .,�e7� <br />