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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MIT <br />SERVICE REQUEST IVvrr�.—rte -- - <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />I � <br />7 Zo mil zvl1�� <br />ACCEPTED BY: <br />�r �C <br />�-�IA <br />OWNER / OPERATOR <br />ASSIGNED TO: <br />CHECK If BILLING ADDRESS <br />O S -e— <br />i L <br />DATE: 17 <br />FACILITY NAME <br />SERVICE CODE: <br />SITE ADDRESS GSI <br />I <br />C D IF V0 <br />Amount Paid <br />Payment Date <br />Payment Type <br />Street Numbe <br />DirectionStreet <br />Name <br />Received By: <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(2-,-','c0 4ZW-4c)g <br />05-1 <br />PHONE #T EXT. <br />BOS DISTRIC <br />LOCATION CODE <br />REQUESTOR <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />CITY <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRE <br />PHONE # <br />FAX # � <br />- 4AI <br />STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized ag6l'twP, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this p <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 d F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 0 11 �7ic�7i0r! <br />T <br />PROPERTY / BUSINESS OWNER 13t OPERA R / ER ❑ OTHER AUTIIORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located" at th� <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: t-, <br />A/j —,orn aJ,i <br />COMMENTS: <br />I � <br />7 Zo mil zvl1�� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: 17 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P I E' v <br />Fee Amount: SZ <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # L, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 EPT�T <br />