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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID #=S-40 <br />RVICE REQUEST # <br />AR 2.8 1012 <br />HEALTRIi DNCO�yVONON <br />RMEqT <br />PHONE# EXT. <br />950-0 <br />OWNER/ OPERATOR A <br />{.t I/I 1 n �/ <br />CHECK If BILLING ADDRESS <br />`it // <br />1 `t' I �V //C. <br />FAX# <br />FACILITY NAME <br />STATE C ZIP G'I J 'L <br />DATE: <br />Date Service Completed (if already completed): <br />C <br />SERVICE CODE: O <br />(. <br />/O� <br />Amount Pai <br />�1 X711 <br />1SITEADDRESS <br />I Street Number <br />Olrectlon <br />L 00( <br />Street Name <br />cityZI <br />Recei ed By: <br />Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Q D Uj< <br />Street Number <br />Street Name <br />CITY pp <br />MFg <br />STATE ZIP <br />PHONE#1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(Z&1) 7��r- q3I <br />PHONEY EXT. <br />l ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTOR I` <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEJ r <br />AR 2.8 1012 <br />HEALTRIi DNCO�yVONON <br />RMEqT <br />PHONE# EXT. <br />EMPLOYEE #: <br />DATE: <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY �l O <br />STATE C ZIP G'I J 'L <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQUTN <br />COUNTY Ordinance Codes, Standards, STATE and F ORAL laws. <br />APPLICANT'S3-26-2-7- SIGNATURE: I I� DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPE OR/MANAGER L!f OTHER AUTHORIZED AGENT❑ <br />ifAPPLICANT 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. PAYA#Pki r <br />TYPE OF SERVICE REQUESTED: C <br />CEIV <br />COMMENTS: <br />AR 2.8 1012 <br />HEALTRIi DNCO�yVONON <br />RMEqT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: O <br />Pi E: 2 <br />Fee Amount: l(r/17i <br />Amount Pai <br />/5,? O <br />Payment Date Z <br />Payment Type <br />Invoice # <br />Check # /Lf,/ 236 <br />Recei ed By: <br />EHD 48-02-025 /t,p b�n r `' SR FORM (Golden Rod) <br />REVISED 11/17/2003 1Y fes, Lio-DJ <br />