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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRES5 ❑ <br />FACILITY NAME <br />SITE ADDRESS <br />.C.FStreet Number Direction Street Name 7L CL 9 zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />StreeE Number rest ame <br />CITY STATE ZIP <br />PHONE 91 EXT, APN # LAND USE APPLICATION # <br />PHONE #T EXT' BOS DISTRICT LOCATION CODE <br />CONTRACTOR /SERVICE REOUESTOR <br />REauESTOR j� , <br />`( -e r.1 (� /� Cj, U ` -Do eJ CHECK If BILLING ADDRE$$ <br />BUSINESS NAME / V 1 PT!! , $ � 5 � EXT, <br />HOME or MAILING ADDRESS FAX# <br />CITYash V' C / STATE 77V; ZIP <br />BILLING AfrKNOWLEDGEMENT: t, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project SpeCIfIC ENVIRONMENTAL HEALTH DEPART1v1ENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form, <br />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, AT and FEDERAL laws. <br />S SIGNATURE:c��.0 /e7 f"11 <br />l <br />iINESS OWNER ❑ OPERATORI MANAGER (3 OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY. proof of authorization f0 sign is required Title <br />AUTtfORIZATt�N TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it is available and at the Same time it is provided t0 me Or <br />my representative. r% <br />TYPE OF SERVICE REQUE <br />STED: SOV <br />� �F <br />COMMENTS: <br />Ro Qu//v X04?? <br />NTy <br />Tye p�R�r O47P A <br />ACCEPTED BY: rextI V <br />EMPLOYEE M <br />DATE: 12.12 -7 .2 Z-. <br />ASSIGNED TO: _ Z Cf �' , ��� > - <br />EMPLOYEE #: <br />DATE: j Zl Z�7 Z Z. <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />&7 S' PIE: ZJI� <br />ce C <br />Fee AmountoIII) -720 <br />Amount Paid <br />E72, .00 <br />Payment DateLY <br />Payment Type V �5� <br />Invoice # <br />Check # �ST 5 % <br />�(o� <br />Received By: <br />£HD 48-02-025 SR FORM (Golden Rod) <br />07/17!08 <br />