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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />, <br />U � U D <br />FACILITY ID # <br />PDQ t:# O V ` az-EXT. <br />SERVICE REQUEST # <br />Jo'IQ''Jtty <br />CITY L� L.R STATE ZIP 1�fszJ I Z - <br />OWNER / OPERATOR <br />EMPLOYEE #:SET <br />ASSIGNED TO: F,IC. n <br />l <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: 3 <br />Fee Amount: Lj <br />SITE ADDRESS ?r�eet <br />J 'str <br />Paid <br />[:1�(•, <br />Payment Type <br />Invoice # <br />G)SZI.,� <br />1 <br />umber <br />Dlrection <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT, <br />c ) <br />APN # <br />C) S- 0 <br />LAND USE APPLICATION # <br />P,A-dR0003) /30 <br />PHONE#Z EXT. <br />BOS DISTRICT L <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />, <br />U � U D <br />BUSINESS NAME <br />PDQ t:# O V ` az-EXT. <br />HOME Or MAILING ADDRESSFAXt# <br />3 far <br />Jo'IQ''Jtty <br />CITY L� L.R STATE ZIP 1�fszJ I Z - <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. q <br />APPLICANT'S SIGNATURE: G " DATE: 1 �Z <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 t0 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: Soil 5U;fr,6- ll} <br />G nC LOC, 41 - 4,J� 611)eVJ <br />COMMENTS: <br />Jo'IQ''Jtty <br />ACCEPTED BY:Z�- L <br />EMPLOYEE #:SET <br />ASSIGNED TO: F,IC. n <br />EMPLOYEE#: DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 <br />Fee Amount: Lj <br />Amount <br />Paid <br />Payment Date l ( 12 <br />Payment Type <br />Invoice # <br />hee 2O" 11—i <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />