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SAN JOAQUOOUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�::4FEAXO <br />r� <br />LA -000 I <br />l <br />Sf�006_7t 5I <br />c,—#,° <br />�` <br />CITY <br />STATE /7 <br />ZIP <br />OWNER1 <br />PERATOR <br />J <br />- <br />CHECK If BILLING ADDRESSAli <br />EMPLOYEE #: <br />A <br />Date Service Completed (if already completed): <br />FACIUTY NAME <br />PIE: Z© <br />L-) <br />Amount PaidPayment <br />Date <br />SITE ADDRESScp, <br />Invoice # I <br />Check # ,. f <br />" v <br />j! <br />Street Number <br />it <br />treat N e <br />CiZit) Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�, t <br />J <br />s' i x <br />Street Number <br />Street Name <br />CITY <br />c to, <br />"STATE ZIP <br />CA 17�JL7 <br />PHONE #1 <br />(Zpci ) {3/ - b`/S _�' <br />EXT <br />APN # <br />IC] U 7 C3 OZ <br />LAND USE APPLICATION # <br />PHONE#2 <br />_2 r <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />q 0 <br />n3 1 S <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />p< o <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br /><�.., r <br />�::4FEAXO <br /># <br />ExT. <br />f <br />�! —Vie <br />HOME or MAILING ADDRESS <br />SAN <br />JOAOUIN COUNTY <br />CITY <br />STATE /7 <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 dome in accordance with all SAN JOAQUIN <br />COt aNTY Ordinance Codes, Standards, STATE and FEDERAL laws, <br />APPLICANT'S SIGNATURE: _ _ - - _ DATE: 2 <br />PROPERTY/ BuswESs OwNFR❑ OPERATOR/ MANAGER © OTHER AUTHORIZED AGENT ® <br />ffAPPLIC.ANT is not the BILLING 1'4ItTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br />TYPE OF SERVICE REQUESTED; { " f O <br />COMMENTS: <br />RECEIVED <br />AUG 2220d3 <br />SAN <br />JOAOUIN COUNTY <br />NVIROM NTAL <br />ACCEPTED 13Y' �r��.11_n T I <br />7� tom—` S <br />EMPLOYEE #: <br />DATE: 73ASSIGNED <br />TO: G <br />EMPLOYEE #: <br />DATE: `j� 13 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ! <br />PIE: Z© <br />Fee Amount: LI -0 <br />Amount PaidPayment <br />Date <br />Payment Type <br />Invoice # I <br />Check # ,. f <br />R ceived By: <br />EHD 4$-02-025 SR FORM (Golden Rod) <br />REVISED 11117!2000 <br />