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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />',ICJ t � <br />0—MIVED <br />FACILITY ID # <br />ERVICE REQUEST # <br />CALL(209)953-7697 <br />Q05) o5-2 6 <br />HOME Or MAILING ADDRESS// <br />I I � � E - �fC _�L lC C�� ICU <br />FOR INSPECTION. <br />FAX# <br />( ) <br />CITY `TJ <br />STATE ZIP (T 3� <br />,lOAQUIN COUNTY <br />REQUIRED. <br />ENVIRONMENTAL <br />O R / OPERATO�� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />�11 <br />// <br />SERVICE CODE: D(— / <br />CHECK if BILLING ADDRESS <br />Fee Amount: <br />��GP <br />/J Ud <br />Payment Date <br />% Z Z— <br />Payment Type <br />FACILITY NAME <br />Check # <br />Received By: <br />SITE ADDRESS <br />L I I <br />j I <br />h� y� <br />S 1j �� <br />`S Street Number <br />Direction <br />treet Name <br />r Cit <br />21 Code <br />HOME or MAILING ADDRESS (If Different fro'f�I1 <br />Site Address) <br />L' �C <br />C l�t_`rLL <br />12 LCStreet Number <br />Street Name <br />STATE <br />ZIP <br />PHONE#i <br />EXr. <br />APN # <br />LAND USE APPLICATION # <br />Pb CP b, <br />U5, <br />PHONE #2 <br />EXT. <br />BOS DISTRICTLOCATION <br />q <br />COD <br />(-) ) I- 7 <br />CONTRACTOR / SERVICE REQUESTOR <br />Rg UESTOR _ <br />CHECK If BILLING ADDRESS <br />',ICJ t � <br />0—MIVED <br />BUSINESS NAME <br />PHONE# EXT. <br />CALL(209)953-7697 <br />Q05) o5-2 6 <br />HOME Or MAILING ADDRESS// <br />I I � � E - �fC _�L lC C�� ICU <br />FOR INSPECTION. <br />FAX# <br />( ) <br />CITY `TJ <br />STATE ZIP (T 3� <br />,lOAQUIN COUNTY <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. I <br />APPLICANT'S SIGNATURE:l� // DATE: <br />PROPERTY/ BUSINESS OWNER D 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 />Y EQUESTED: �P f, 5� 7 bG� L �s <br />�t O�u't S' I c 3 S f . �a c t' meo <br />e�1 10;1 . <br />0—MIVED <br />CALL(209)953-7697 <br />A 2U22 <br />FOR INSPECTION. <br />24-HOUR NOTICE <br />,lOAQUIN COUNTY <br />REQUIRED. <br />ENVIRONMENTAL <br />D Y: �� fi <br />s� <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: 3l /4/ <br />Date Service Completed (if already completed): <br />SERVICE CODE: D(— / <br />P / E: a �a <br />Fee Amount: <br />Amount Pai <br />/J Ud <br />Payment Date <br />% Z Z— <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />