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SAN JOAQU... COUNTY ENVIRONMENTAL HEALTH —:PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />OWNER PERATOR <br />M^ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME) <br />HOME or MAILING ADDRESS /t <br />/ t <br />SITE ADi)RES <br />GY Street Number <br />Direction <br />�it�` L <br />Street Name <br />City <br />( Q? l 2 <br />e <br />E or MAILING ADDRESS (If Different from Site Address) <br />C' -C� -e- V v Street Number <br />EMPLOYEE #: <br />Street Name <br />CITY OC r <br />STATE <br />�, <br />ZIP <br />j <br />PHONE #1 ExT• <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PHONE #ExT• <br />CCQ L <br />HOME or MAILING ADDRESS /t <br />/ t <br />FAX # <br />CITY vtc.0 it <br />STATE 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 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 SIGNATURE: - — DATE: �2— 2 1 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER I 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided o me or <br />my representative. rw11FN r. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />CCQ L <br />ACCEPTED BY:/ <br />�� <br />I4"/,'/ <br />EMPLOYEE #: <br />��i! <br />J2 <br />DATE: <br />ASSIGNED TO: <br />T— <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: /Gi� <br />PIE: 2-30ff <br />Fee Amount: <br />3 7$ oa <br />Amount Paid IF 3-7S-, CrD <br />Payment Date <br />--l-Ig / i3 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />CZ yr-" � bzrLf, FA <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />