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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 />FACILITY ID # <br />l <br />SERVICE REQUEST # <br />HOME Or MAILING ADDRESS( <br />°(:C r <br />�IARQ045Hyep <br />CO Z <br />"gLTy OFpq gT7AJ <br />�' 1)C��1 <br />�I'� <br />5R�d08Co143 <br />OWNER/OPERATOR �- <br />EMPLOYEE #: <br />( ) <br />CITYS+u' <br />% <br />CNECK If BILLING ADDRESS <br />C <br />PIE: ?f <br />Fee Amount: <br />FACILITY NAME <br />Amount Pal <br />O v <br />Payment Date <br />/�2_ <br />SHEAR RESS <br />A <br />Check # <br />[LJ <br />I 'D n r 60j4'W <br />V <br />Dlrectloe <br />of a e <br />CI <br />ZI Coda <br />HOME or MAILING RESS (If Different from Site Address) <br />pp <br />l., Street Number <br />al Nama <br />CITYTATE <br />ZIP <br />PH E# Err. <br />APN # <br />LAND USE APPLICATION # <br />(7D <br />PHONE#2 Exr. <br />I ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR N . <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />/1 <br />BUSINESS NAME t / <br />l <br />PHONE# En. <br />HOME Or MAILING ADDRESS( <br />°(:C r <br />�IARQ045Hyep <br />CO Z <br />"gLTy OFpq gT7AJ <br />ACCEPTED BY: V� w s G"� <br />FAR# <br />III <br />ASSIGNED TO: 0-'rrtkesC 0 <br />EMPLOYEE #: <br />( ) <br />CITYS+u' <br />% <br />- STATE ZIP r <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. /� <br />APPLICANT'S SIGNATURE: DATE: k 10 I�� _ <br />PROPERTY/ BUSINESS OWNER -I OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If <br />If APPL7CANTisnolthe BrLLlNGPARTY 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 enviromnental/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. Ae <br />TYPE OF SERVICE REQUESTED: <br />kk LAJ <br />k ftl--. <br />R <br />COMMENTS: <br />r li <br />°(:C r <br />�IARQ045Hyep <br />CO Z <br />"gLTy OFpq gT7AJ <br />ACCEPTED BY: V� w s G"� <br />EMPLOYEE #: <br />DATE: I LL �2 <br />ASSIGNED TO: 0-'rrtkesC 0 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: © <br />PIE: ?f <br />Fee Amount: <br />-00 1 <br />Amount Pal <br />O v <br />Payment Date <br />/�2_ <br />Payment Type Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />fT <br />D <br />'ero5-IB 13g 5 <br />