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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTI-OPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r 'j'j,� <br />CHECK if BILLING ADDRESS II <br />FACILITY ID # <br />SERVICE REQUEST # <br />C <br />F- <br />�'CO(I A5V <br />s� 5R8 �o <br />OWNER /OPERATOR <br />Er✓l <br />' 1 c <br />ft pt q <br />ll�� J <br />�l <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME <br />Thorn+on <br />c f. <br />K. <br />SITE ADDRESSK-I--r�� <br />ACCEPTED BY: �� (v ��Q — <br />r ' ` <br />` Y 1 'StUreet <br />•J t V`� V <br />I <br />treetNumber <br />Direction <br />#: <br />Name <br />Cit' <br />zip Cococ <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: <br />q <br />P1 E: <br />Fee Amount: S () <br />Street Number <br />Street Name <br />CITY <br />Payment TypeL� <br />STATE ZIP <br />PHONE#1 EXT. <br />( ) 4113-B1 <br />Check # -��� <br />APN # <br />Received By: <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />,"G <br />MPU <br />r 'j'j,� <br />CHECK if BILLING ADDRESS II <br />BUSINESS NAMEPHONE# <br />Apec" <br />COMMENTS: <br />-/^O EXT. <br />(20q)0 IiCJ <br />14� <br />HOME Or MAILING ADDRESS �•� � 5f) IDS <br />FAX# <br />( - <br />) 'ILIuo <br />CITY trtocimn <br />STATE ZIP %j VD <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 <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 <br />Iand <br />` FEDERAL laws. <br />APPLICANT'S SIGNATURE: �L DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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. <br />TYPE OF SERVICE REQUESTED: -i <br />ce `� I T <br />pAYMF-NT <br />COMMENTS: <br />MAy - 4 2®10 <br />SANN\P RONMEN�EN <br />HEAI-TM OEPAR <br />ACCEPTED BY: �� (v ��Q — <br />r ' ` <br />EMPLOYEE #: Q <br />DATE: <br />I(� <br />ASSIGNED TO: <br />, k LisEMPLOYEE <br />#: <br />DATE: _ _6� U <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />q <br />P1 E: <br />Fee Amount: S () <br />Amount Paid <br />t3L�S: <br />Payment Date <br />Payment TypeL� <br />Invoice # <br />Check # -��� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />