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SAN JOAQUINRUNTY ENVIRONMENTAL HEALTH IDORTMENT <br />SERVICE REQUEST <br />Type of Busines or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />WA <br />CHECK if BILLING ADDRESS <br />5P-00, fo 2 P -3 <br />OWNER/ OPERATOR <br />BUSINESS NAME <br />p <br />1 r <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />X1 M <br />ACCEPTED BY: <br />EMPLOYEE #: <br />SITE ADDRE S <br />a reef um or Direction <br />1 V <br />Stse�etlFba e� `� <br />FAX # <br />Ctt <br />erode <br />HOME or MAILING ADDRESS (If Diff ent from Site Address) <br />ZIP <br />J—.,..t <br />Amount Paid 0-3 L L- b i7 <br />StreetNumber <br />Name <br />CITY <br />Received By: <br />STATE ZIP <br />PHONE #t EXT. APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />s ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />P.EQUESTOR <br />PA Y III <br />❑ <br />CHECK if BILLING ADDRESS <br />Tlf <br />BUSINESS NAME <br />PHONE# <br />EXT. <br />(� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: %/^.�, l <br />)-TOME or MAILING ADDRESS <br />EMPLOYEE #: <br />FAX # <br />Date Service C pleted already completed: <br />CITY b <br />STATE <br />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, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ,,- � - DATE: Z� <br />PROPERTY / BUSINESS OWNEREI OPERATOR / i♦IANAGFR D OTHER AUTHORIZED AGENTA <br />If,4PPLICANT is not the BILLING PAR77proof 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 COLTNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: l <br />PA Y III <br />COMMENTS: <br />SUN 2 4 �O1t <br />Tlf <br />SAN JoADut coot <br />LI'14O.1AgTMENT <br />yIEAL�N <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: %/^.�, l <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: V V-/1 <br />Date Service C pleted already completed: <br />I <br />SERVICE/ CODE: <br />P l E: <br />Fee Amount: 13 <br />Amount Paid 0-3 L L- b i7 <br />Payment Date I- <br />Payment Type m. Invoice # <br />Check # JLff 27 4 9 tF.;Z co" <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />