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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />i SERVICE REQUEST r <br />Type of Busines <br />or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE <br />EXT' <br />HOME Or MAILING ADDRESS <br />T� <br />/` <br />�1-N/V <br />OWNER/OPE <br />TOR <br />0C�.37 <br />CHECK BILLING ADDRESS E] <br />P I E: <br />CITY <br />STATE qt <br />If <br />Payment Date <br />(S <br />Payment Type '-�- <br />I Invoice # <br />FAC ME <br />Received By: <br />r <br />SITE ADDRESS''tct <br />� <br />Street Number Direction <br />Street Name <br />cityZi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Sheet Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #t) <br />T• <br />APN # / D <br />LAND USE APPLICATION # <br />PHONE#2 <br />ExT• <br />BOS DISTRI <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST <br />YrN�V <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />ACCEP ED BY: <br />PHONE <br />EXT' <br />HOME Or MAILING ADDRESS <br />EMPLOYEE #: O �� <br />FAx <br />c;I) <br />�/ <br />_ / 3r{e� <br />SERVICECODE: aO <br />P I E: <br />CITY <br />STATE qt <br />P <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 or <br />activity will be billed to me or my business as identified on this form <br />I also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar TATE and FEDERAL laws. <br />1041-2 <br />APPLICANT'S SIGNATURE:MA V&A DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILL(NGPARTY 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 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, nCN' <br />TYPE OF SERVICE REQUESTED: ��7 <br />YrN�V <br />COMMENTS: <br />B EN`1iPO1NJME ME <br />vol -TV, DEPART <br />ACCEP ED BY: <br />EMPLOYEE #: S�b <br />DATE: 9/ O� <br />ASSIGNED TO: - <br />EMPLOYEE #: O �� <br />DATE: 9jO <br />Date Service Completed (if already completed): <br />SERVICECODE: aO <br />P I E: <br />Fee Amount: a-�� <br />Amount Paid <br />S S, <br />Payment Date <br />(S <br />Payment Type '-�- <br />I Invoice # <br />Check # \ �`� S <br />Received By: <br />EHD 48-02-025}-'-:SR-FORM (Golden Rod) <br />REVISED 11/17/2003 <br />