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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE # EXT. <br />FACILITY ID # <br />FAX# <br />( <br />SERVICE RECAJEST # <br />EN <br />0 �QViN <br />�conT� �Y <br />ACCEPTED BY: <br />��-g <br />C'O n'/ l L <br />DATE: i <br />�3aa <br />ASSIGNED TO: (� <br />EMPLOYEE #: <br />DATE: S� �3/a 1 <br />OWNER / OPERATOR <br />SERVICECODE: <br />Ey <br />FA � <br />P L L C <br />��� �� <br />CHECK if BILLriG ADDRESS <br />FACILITY NAME <br />Invoice # <br />7 <br />Check # <br />SITE ADDRESS 17,900 <br />E <br />ZAM /e0(C%—)-- <br />/Fox/ <br />9Is-. i <br />Street Number <br />Direction <br />Street Name <br />C ity <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />15;km& <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT• <br />APN # <br />LAND USE APPLICATION # <br />49k,2 -4,2- <br />PHONE#2 <br />( ) <br />EXT <br />BOS DISTRICT <br />LDC'TIDN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR b/V G CHECK if BILLIIG ADDRESS E] <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />( <br />CITY STATE ZIP LK <br />/ <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 a ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards 7ATE and RAL laws. <br />APPLICANT'S SIGNATURE: DATE: S <br />PROPERTY / BUSINESS OWNER❑ OPERATO / 1VIAN.4GER❑ OTHER AUTHORIZED AGENT Q <br />If APPLICANT is not the BILLING PARTY proof f authorization to sign is required TiCe <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 />A's a <br />TYPE OF SERVICE REQUESTED: L <br />V <br />COMMENTS: <br />dtr,,�Y 0 <br />3 20 <br />22 <br />EN <br />0 �QViN <br />�conT� �Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: i <br />�3aa <br />ASSIGNED TO: (� <br />EMPLOYEE #: <br />DATE: S� �3/a 1 <br />Date Service Completed (if already completed: <br />SERVICECODE: <br />G�6Qp7 <br />P'E.$60 <br />Fee Amount:' P. x e <br />Fie <br />$Amount P <br />��� �� <br />Payment Date 3 <br />Payment Type <br />Invoice # <br />7 <br />Check # <br />Received By: <br />EHD 48-02-025 () proJ ��X�Qd(t�Tc� 1 �`�� SR =ORM (Golden Rod) <br />REVISED 11/17/2003 rc- r, I °�� b °� `e ` '5-/13/E6 zz <br />