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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME _ PHONE # EXT. <br />FACILITY ID # <br />SERVICE REQUEST # <br />40 5'1�) tao� <br />) <br />CITY / C 01,W STAT zip f© <br />54C670S`Li <br />OWNER //OPERATOR <br />DATE: <br />'1✓)LJi/ <br />CHECK if BILLINGADDRESSE] <br />FACILITY NAME (, <br />DATE: . <br />i CIC / )J'N <br />ns _ X-uyt LL ii <br />SERVICE CODE; <br />SITE ADDRESS <br />s <br />PIE:�� <br />7 <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY _ <br />STAre zip <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />i ) <br />EXT. <br />BIOS DISTRICT <br />LOCATION COD£ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING AODRESS <br />BUSINESS NAME _ PHONE # EXT. <br />HOME or MAILING APDRESS <br />FAX If <br />'?T1 Z"01 d J Al -vii 211.1—( <br />) <br />CITY / C 01,W STAT zip f© <br />BILLING ACKNOWLEDGEMENT: 1, 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 />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 SIGNATU E:f DATE: <br />PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPzrcANI is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property locat t the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assess �tio <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it ISMr <br />my representative. C�IV&r-. <br />TYPE OF SERVICE REQUESTED: 1ASTUaf:'C[ <br />AMR;) <br />COMMENTS: <br />LA S7 <br />['®v� S u '1�t OYi <br />8AN <br />'r�VIR QUl/y C <br />kEkr � pMc-1V rUL <br />A'�T"' t <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: . <br />Date Service Completed (if already co pleted): <br />SERVICE CODE; <br />�j <br />PIE:�� <br />Fee Amount:C'L3 <br />Amount Pai <br />` ,/� <br />Payment Date <br />Payment Type � <br />Invoice # <br />Check # �Q j <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07117/08 <br />