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SAN JOAQU NTY ENVIRONMENTAL HEALTH ftRTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />S <br />BUSINESS NAME I <br />COMMENTS: <br />PHONE# Ezv. <br />FACILITY IDK # <br />SERVICE REQUEST # <br />OWNER/OPERATOR <br />CITY <br />STA 4 ZIP <br />- <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE; I'�O <br />ASSIGNED TO: <br />LA <br />EMPLOYEE #: '., ab --7p <br />SITEADDRESS <br />Date Service Completed (if already completed): <br />�.�.CttiA � c�-- <br />/c.f�. <br />�.'Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Fee Amount: <br />Street Name <br />8 $ � <br />CITY <br />V 6 L <br />STATE <br />ZIP <br />Check # OI <br />PHONE #1 ExT' <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / ffe�ll <br />LC�-2L CHECK If BILLING AODRESSL�I <br />BUSINESS NAME I <br />COMMENTS: <br />PHONE# Ezv. <br />HOME or MAILING ADDRESS <br />4-7 L✓x'/41'-> <br />.. <br />FAX# <br />(� ) S 53 <br />CITY <br />STA 4 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 spe IfiC 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 ;III SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: L <br />DATE: <br />PRO PERTY/BUSINESSOWN ER❑ OPERA OR/ MANAGER 11 OTHER AUTHORIZED AGENT ❑ �j:�'g-f CG' <br />IfAPPLICANT is not the BILLI C PARTY proof of authorization to sigh is required Tree <br />AUTHORIZATION TO RELEASE INF RMATION: 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 environmentallsite assessment <br />infortnation 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, nV HENT <br />TYPE OF SERVICE REQUESTED: <br />RECE��� <br />COMMENTS: <br />1^A1 Q qoo <br />JH'`t O L <br />I <br />SA ENVIRONMENT <br />HEAI-TN DEPART <br />ACCEPTED BY:n/ <br />I <br />EMPLOYEE #: �'I (O <br />DATE; I'�O <br />ASSIGNED TO: <br />LA <br />EMPLOYEE #: '., ab --7p <br />DATE: Sr•„f1 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ql <br />PIE: , r�7 <br />YJ <br />Fee Amount: <br />I Amount Paid <br />8 $ � <br />Payment Date \ <br />V 6 L <br />Payment Type l� <br />Invoice # <br />Check # OI <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />V.I <br />