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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 />SERVICE REQUEST # <br />BUSINESS NAME <br />PHONE # EXT. <br />ACCEPTED BY' <br />OWNER I OPERATOR <br />Zoq 1 + 5 <br />CHECK ((BILLING ADDRESS <br />S o r✓t <br />{FACT -NAME <br />�- r/1 <br />FAX # <br />?SITE ADDRESS <br />l ) <br />-JA-V1 <br />„� ^ <br />/ <br />Street Number <br />Direction <br />Street Name <br />Cit <br />ZI COEo <br />,HSE Or MAILING ADDRESS �(If Different from Site <br />Address) 3 R <br />A— -e <br />T� �/ <br />- <br />Stroct Numbor <br />Street Name <br />CITY r,- ^^' <br />`( � i7 <br />$TATE CA ZIP <br />'PH Nei E-* <br />-flll'I ICbq _Q9 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />,REQUESTOR� //'' <br />CHECK If BILLING ADDRESS <br />0 S IzOY/tE <br />COMMENTS: <br />BUSINESS NAME <br />PHONE # EXT. <br />ACCEPTED BY' <br />Zoq 1 + 5 <br />HOME Or MAILING ADDRESS <br />DATE: <br />FAX # <br />h 1 1 (Z V "O lE 5 <br />l ) <br />CITY •7 1r--- <br />5 70 <br />STATE c n ZIP G C ^i <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sane, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:DATF_: • <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />If APPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environ / ite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avails aQd�e.M�li a it is <br />provided to me or my representative. 4 1T,_�r��_�o <br />TYPE OF SERVICE REQUESTED: 1 W V V VL( 1 7e <br />\�-, <br />$& <br />COMMENTS: <br />N BINCQ l <br />� <br />R�V <br />�OipFN <br />�1RT� <br />T,yFNT <br />ACCEPTED BY' <br />EMPLOYEE #: qp)(? <br />DATE: <br />ASSIGNED TO: OLIA'mt <br />EMPLOYEE#: qgrx <br />DATE: C7kyr <br />Date Service Completed (if already completed): <br />SERVICE CODE: O'n I <br />PIE: <br />Fee Amount <br />Amount Pai /VO OZ) <br />Payment Date 2 <br />Payment Type <br />Invoice # <br />Check # <br />Keceivdd By: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />QF -015N-11233 <br />SR FORM (Golden Rod) <br />