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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/j/ <br />'/ / / <br />( <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />a t <br />FAX# <br />SITE ADDRESS <br />/� Street Number <br />DircU n <br />6-11 r <br />t <br />EMPLOYEE #: <br />DATE: r� J <br />z1 <br />HOME or MAILING ADDRESS (If Different from Site Address <br />Street Number <br />EMPLOYEE #: <br />Street Name <br />CITY <br />SERVICE CODE:jr C, b� <br />STATE zip <br />PHONE #'I EXT. <br />APN # <br />Payment Date <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORJ /y <br />Al f /t la <br />�(� <br />/j/ <br />'/ / / <br />( <br />CHECK If BILLING ADDRESS Lf <br />BUSINESS NAME <br />_ <br />PH <br />HOME or MAILING ADDRESS% <br />a t <br />FAX# <br />41 <br />CITY / <br />STATE <br />zip <br />BILLING ACKNOWLEDGEMENTYI, 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 S0 perform d will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE ani ttEDE law . <br />�' <br />APPLICANT'S SIGNATURE: / / DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / ANAGERA OTHER AUTHORIZED AGENT ❑ oAvM ENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign: is required Title REC��E� <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located a 1 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sitgz s2nTi <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same Ime I. <br />provided to me or my representative. SAN JOAQUIN COUNTY <br />^ AL <br />TYPE OF SERVICE REQUESTED: \ 4 I-V P MENT <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: aL/� <br />a t <br />41 <br />6x d ve r <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: r� J <br />z1 <br />ASSIGNED TO: ti <br />CZ, <br />EMPLOYEE #: <br />DATE: Z <br />Date Service Completed (if already completed): <br />SERVICE CODE:jr C, b� <br />P / E: Z0 Z <br />Fee Amount: 5�Z <br />Amount Paid d( l5 Z _ <br />Payment Date <br />Z-� Z -2-- <br />Payment <br />Payment Type <br />c4lI <br />Invoice # <br />Check #Gt a <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />