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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTI' 'DEPARTMENT <br />SERVICE REQUEST <br />or Property <br />Type of BusMco <br />%�1U <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />HOME Or MAILING ADDRESS /j <br />ACCEPTED BY: <br />FAX# <br />CITY ` �' �y <br />STATE C^5z s ZIP <br />atC <br />ASSIGNED TO: . U)l / <br />OWNER / OPEt6%4W-W/VJ <br />EMPLOYEE #: <br />z6p <br />0�CHECK If BILLING ADDRESS <br />FACILITY NAME <br />0 C) <br />SERVICE CODE: `i f <br />P 1 E:� 3 O <br />SITE ADDRESS <br />Amount Paid <br />Payment Date (G a S <br />/ 1L <br />Invoice # <br />Street Number <br />Direction <br />1, l ,` X Str� Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS . (If Different from Site Address) <br />PowpblAtt <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />( .) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />• <br />REQUESTOR (�ol <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PGE# EXT, <br />HOME Or MAILING ADDRESS /j <br />ACCEPTED BY: <br />FAX# <br />CITY ` �' �y <br />STATE C^5z s ZIP <br />atC <br />BILLING ACKNONV DGEMENT: 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 or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this/1 plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar s, TAT aF nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: iCL`�lt� ffl'i �f I DATE: 69 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT e a'SIC(. <br />� <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 />movided to me or my representative. „,,n „ h I T <br />TYPE OF SERVICE REQUESTED: (.G j T <br />i/civ `/ <br />RECEI`f F_ ❑ <br />COMMENTS: <br />UN 2 7 7005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: . U)l / <br />EMPLOYEE #: <br />Q 3 <br />DATE: Q <br />Date Service Completed (if already completed): <br />SERVICE CODE: `i f <br />P 1 E:� 3 O <br />Fee Amount: -2 7q DD <br />Amount Paid <br />Payment Date (G a S <br />Payment Type <br />Invoice # <br />Check # 9�2 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />