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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CA—PHONE <br /># I E. <br />S,� OD49to0 <br />OWNER / OPERATOR <br />FAX# <br />V , / <br />av r <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />He4pr <br />SITE ADDRESS SSII _ <br />I�SIFe�Number <br />DEp� MAL <br />Let <br />\pp` <br />Direction <br />Street Nam. <br />z Sod <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />ASSIGNED TO: <br />0' bN 112.5 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP C4 <br />r <br />T J V) <br />PHONE #i E'R• <br />APN# <br />Fee Amount: SAD <br />LANDU APPLICATION# <br />Payment Date <br />W22 <br />Payment Type <br />PH NE #2 Exr• <br />( ) <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 00,A- <br />�,J <br />V o <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />CA—PHONE <br /># I E. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITUI I Kr U ��7r& <br />STATE ZIP <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 a t t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA d FE L laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTO <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 die SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the SPA <br />A time it IS <br />provided to me or my representative. i'�Y <br />TYPE OF SERVICE REQUESTED:f-M �" CES <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />P�51 to 15 <br />COMMENTS: <br />NOV t <br />zo2 <br />$AlyJOAQijCO <br />He4pr <br />DEp� MAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Co1.mpleted (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: SAD <br />Amount Paid <br />l S(v b T <br />Payment Date <br />W22 <br />Payment Type <br />Vi�-- <br />Invoice # <br />Check # /S3 OS 3g <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />P�51 to 15 <br />