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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST • <br />T of Bu ' <br />s or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SP on ` f boc�g <br />W ER/OPERATOR <br />l <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HOME Or MAILING A.DDR SSFAx# <br />a <br />( �- <br />SITE ADDRESS �Ypl�1 <br />Srreo Number DIL ion <br />Str Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY kml <br />STATE ZIP <br />PHONE #t �'T <br />APN # <br />Amount Paid a�(� <br />LAND USE APPLICATION # <br />PHONE#2 <br />Payment Type <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />CHECK If BILLING ADDRE <br />BUSINESS N E <br />O 2006 <br />MAR 9 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE / T. <br />l <br />HOME Or MAILING A.DDR SSFAx# <br />a <br />( �- <br />Cm <br />e7n $SATE 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 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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATEFEDERAL laws. ��/uj/�� / <br />APPLICANT'S SIGNATURE: �Jl %lT , I , l ! I A /I O A i DATE: �J — 1'Z39 U e <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT aJ12A:CXI. j <br />If APPLICANT is not the BILLING PARTY 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. cnl_I <br />TYPE OF SERVICE REQUESTED:RECOVED <br />COMMENTS: <br />O 2006 <br />MAR 9 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M . i�1 0 <br />`-C-3 <br />DATE: <br />ASSIGNEDTO: <br />EMPLOYEE#: 67 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CGDE: <br />P I E:2,30 <br />Fee Amount: <br />Amount Paid a�(� <br />Payment Date <br />319166 <br />Payment Type <br />Invoice # <br />Check # 1 b S S1 <br />Received By: UVB <br />EHD 48-02-025 sR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />