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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST 11 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME Or MAILING ADDRESS <br />FAx# <br />S)Q 002(P01c� <br />:Iacinr c <br />y, N"'Qu' <br />��OFagRT <br />OWNER / OP RATOR <br />\1 <br />CHECK If BILLING ADDRESS <br />Y <br />FACILITY NAME <br />n <br />L <br />EMPLOYEE #: 7-0 <br />V` <br />ASSIGNED TO:/J <br />SITE ADDRESS <br />EMPLOYEE#: <br />Y <br />Date Service Com <br />ed (if already completed): <br />SERVICE CODE: <br />Street Number <br />Direction <br />S�t.l N.�l/mow <br />CI <br />Zip� de' <br />HOME ojr MAILING ADDRESS (If Different from Site Address) <br />.J�- <br />I Invoice # Check # /S2 ,j O I <br />��G <br />T <br />l (� <br />Street Number <br />Street Name <br />CR _4 ` C-"4 <br />4G <br />STAc ZIP sa i a <br />PHOONN�E#i EXT' <br />APN # <br />LAND USE APPLICATION # <br />(r-01 <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/SERVICE QUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# En. <br />HOME Or MAILING ADDRESS <br />FAx# <br />CITY - 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 piojcct 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 />t also certify that I have prepared this a and that the work to be performed will be done in accordance with all SAN. JOAQUIN <br />COUNTY Ordinance Codes, Standa s, STATE and EDERAL laws. <br />APPLICANT'S SIGNA FURg. DATE: <br />PROPERTY / BUSINESS OWNER❑ OP AN.AGER ❑ OTHER AUTHORIZED AGENT ❑ e <br />If APPLIC4AT is not the BILd NGPARTY. 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 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the salrssiiiple it IS <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 1�/ % <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: <br />U <br />1 <br />y, N"'Qu' <br />��OFagRT <br />�N <br />MFM' <br />ACCEPTED BY: <br />EMPLOYEE #: 7-0 <br />DATE: <br />ASSIGNED TO:/J <br />EMPLOYEE#: <br />DATE: /2Z - <br />Date Service Com <br />ed (if already completed): <br />SERVICE CODE: <br />P// E: <br />Fee Amount: <br />Amount Paid /f.G�'� <br />Payment Date <br />gr <br />Payment Type <br />.J�- <br />I Invoice # Check # /S2 ,j O I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />