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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />94logo <br />ACCEPTED BY:if <br />EMPLOYEE #: <br />DATE <br />ASSIGNED TO: <br />WNER /OPERATOR <br />DATE: / ZZ <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />CHECK If BILLING ADDRESS ❑ <br />P / E:' <br />Fee Amount: 5 7 <br />Amount Paid <br />FACILITY NAME <br />Payment Date <br />2�7 <br />SITE ADDRESS <br />Invoice # <br />?J G' <br />Received By: /Ar 77 <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />r <br />Street Number <br />Street Name <br />CITY � p <br />STATE ZIP <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />(209) -54 -051 0 <br />Z 4 005 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �—c r� C � a , DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 <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 />4-o izer <br />COMMENTS: � n ,.� / O � . � <br />44 <br />ACCEPTED BY:if <br />EMPLOYEE #: <br />DATE <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: / ZZ <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E:' <br />Fee Amount: 5 7 <br />Amount Paid <br />Payment Date <br />2�7 <br />Payment Type <br />Invoice # <br />?J G' <br />Received By: /Ar 77 <br />A <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Vr <br />5D <br />