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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />T pe of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE#: C� ( <br />SITE ADDRESS I r ( I f J�V <br />S�ret Number <br />V t \. v <br />DI`r'ection <br />lily <br />�G- ' 1 � Street Name <br />Ci <br />Z' Cod <br />HOME or _MAILINGADDRES ..(Iftttf Differentfrom Site Ad ressG"r) <br />Street Number <br />Street Name <br />CITY ea <br />ry ^ ,AI—^�' STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />( ) <br />2 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <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 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, Standa STATehkhE and FEDERAL laws. + <br />APPLICANT'S SIGNATU��R//E OPERDATE: <br />PROPERTY / BUSINESS OWNER ATOR / MANAGER 13OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is no he BILLING PARTY proof of authorization t0 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 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. T <br />TYPE OF SERVICE REQUESTED: Q ocj `- V+ %- I w n C 1® <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />023 <br />OUNTY <br />TAL <br />TMENT <br />COMMENTS: <br />JUL 10 <br />SAN JOAQUIN <br />ENVIRONME <br />HEALTH PA <br />ACCEPTED BY: vl,� <br />EMPLOYEE#: C� ( <br />DATE: 7/1012-3 <br />ASSIGNED TO: Sino <br />In <br />EMPLOYEE #: <br />DATE: 711012-3 <br />Date Service Completed (if already completed): <br />SERVICECODE: CJj6 <br />1 E: 1031 <br />Fee Amount: `. 2 <br />Amount Paid <br />Payment Date <br />2 <br />Payment TypeC <br />Invoice # <br />Ch c # �� 3 <br />1 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />023 <br />OUNTY <br />TAL <br />TMENT <br />