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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CXECK if BILLING ADDRESS ❑ <br />ECE`► <br />FACILIT� fll # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />PHONE <br />HOME or MAILING ADDRESSFAX# <br />7i <br />EMPLOYEE #; r <br />(2 33e -i-632 <br />CrrY + <br />STATTifl. LP <br />OWNER / OPERATOR <br />DATE: <br />Date Service Completed (N alreacry completed): <br />H BILLING ADDRESS ❑ <br />I E: 6� <br />Fee Amount: ` C)J) <br />Amount Paid <br />CHECK <br />Payment Date <br />r <br />Payment Type <br />Invoice # <br />FACILITY NAME <br />R ceiv d By: <br />V, //at <br />rt <br />yl <br />e <br />3 <br />Street Number <br />DireeNon <br />✓�t��� <br />Zi COAs <br />HOME Or MAILING ADD S (If Di <br />rent from Site Address) <br />/ Street Number <br />Street Name <br />CITY <br />STATr <br />PHONE#f <br />(26 321- 41 <br />FWN# <br />t> 41 z <br />LAND USE APPLICATION It <br />PHONEY <br />EM. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CXECK if BILLING ADDRESS ❑ <br />ECE`► <br />/ <br />BUSINESS NAME <br />EP20201, <br />SgEN AQUIty <br />HEACTN OU <br />OE AEh MAL <br />E <br />PHONE <br />HOME or MAILING ADDRESSFAX# <br />7i <br />EMPLOYEE #; r <br />(2 33e -i-632 <br />CrrY + <br />STATTifl. LP <br />r <br />DATE: <br />V <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST d L s <br />APPLICANT'S SIGNATURE: / DATE: 7 �7 3 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIYED AGENT❑ <br />If APPLICANT is not the BILLING PAR %P proof of authorization to sign is required Tine <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 environmentaUsite 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. Pq <br />TYPE OF SERVICE REQUESTED: Q <br />fQ <br />ECE`► <br />COMMENTS: <br />EP20201, <br />SgEN AQUIty <br />HEACTN OU <br />OE AEh MAL <br />E <br />ACCEPTED BY: <br />EMPLOYEE #; r <br />DATE: ( (� <br />AsSIGNEDTO: <br />EMPLOYEE („ ( <br />DATE: <br />Date Service Completed (N alreacry completed): <br />SERVICE CODE: <br />I E: 6� <br />Fee Amount: ` C)J) <br />Amount Paid <br />O� <br />Payment Date <br />y2_411)3 <br />Payment Type <br />Invoice # <br />Check # 73 8 <br />R ceiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />D <br />wry <br />ir <br />