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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 />FACILITY ID # <br />0.\ � I <br />BUSINESS NAM <br />SERVICE REQUEST # <br />PHONE # E'' <br />5 t e t`c 0 <br />- 0 <br />HOME or MAILINGDRESS <br />9 667 <br />OWNER / OPERATOR <br />00 <br />M pOpgFNTAt <br />CHECK If BILLING ADDRESS <br />CITY �'O <br />C <br />ACCEPTED BY:' <br />FACILITY NAME <br />DATE: d'1 / <br />ASSIGNED TO: <br />I5C <br />e L0. <br />Date Service Completed (if alrea ycompleted): <br />SITE ADDRESS <br />5 <br />PIE: <br />` <br />({�� bJ <br />Amount PAZ <br />ry <br />S O �6 <br />q'SZO2 <br />Stet Number <br />Direction <br />`' Stree Name <br />'L <br />ZiCode <br />HOME Or MAILI ADDRESS (If Different fro <br />[._ <br />Site Address)-ZW <br />SUeet Number <br />Street Nama <br />CITYI <br />p <br />STATE ZIP <br />CR 52 O <br />PHONE #1 Exr' <br />APN # OO <br />LAND USE APPLICATION # <br />2O9) 32+ <br />PHONE #Z En. <br />( ) <br />BOB DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR(� <br />CHECK If BILLING ADDRESS <br />0.\ � I <br />BUSINESS NAM <br />VF <br />PHONE # E'' <br />5 t e t`c 0 <br />- 0 <br />HOME or MAILINGDRESS <br />t <br />FAX <br />00 <br />M pOpgFNTAt <br />( ) <br />CITY �'O <br />C r STATE ZIP C? se4 <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 or <br />activity will be billed to me or my business as identified on this form. <br />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 laws. <br />p( APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER a OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 4r©qLV <br />If APPLICANT 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or <br />my representative. AN g - <br />TYPE OF SERVICE REQUESTED: Fpnri p <br />COMMENTS: <br />- <br />VF <br />Nov 21 , <br />SAN jO4 01? <br />M pOpgFNTAt <br />ACCEPTED BY:' <br />EMPLOYEE M <br />DATE: d'1 / <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if alrea ycompleted): <br />SERVICE CODE: C=�z� <br />PIE: <br />Fee Amount::,f, , <br />Amount PAZ <br />aS b <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 '✓ L ���. <br />[i <br />