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I L4 <br />0 T 1 4 2008 SAN JOAQUi ;OUNTY ENVIRONMENTAL HEALTL ZPARTMENT <br />ENVIROWHNIT HEALTH SERVICE REQUEST <br />T e �u'slne3s br' operty <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />BUSINESS NA E <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />FAX# <br />3�,�� <br />5 co_tsrs7i6' <br />n <br />aAN <br />NVlRODNAR EW <br />OWNER /OPERATOR <br />ACCEPTED BY: [_ t ( P—�2-A <br />EMPLOYEE #:�3 Z <br />DATE: t of <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />EMPLOYEE #: ,/ 'l - <br />DATE: () U C <br />Date Service Completed (if already completed): <br />SERVICE CODE: /C1^ V <br />P I E: L3C <br />ti <br />Amount Paid !� D --[Paymentl <br />SITE ADDR S <br />`t> <br />E mlaa rcadc 1"U t Z JTl_)�ZOon <br />Invoice # <br />Q Sot <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCAT iON CGDE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 6d ti 0 "F_ CrArk 6 E,02 <br />CHECK If BILLING ADDRESS <br />nonilitc <br />BUSINESS NA E <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY 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 <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATODUAl AGER ❑ OTHER AUTHORIZED AGENT ❑ tai r i1, �, S,! ra t VP n I <br />If APPLrcANT is not the BiuiNc 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. T_ f _r co F i`F_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS:RIO <br />J <br />0 j 4 U 2008 <br />jQAQU1N COUNfY <br />aAN <br />NVlRODNAR EW <br />ACCEPTED BY: [_ t ( P—�2-A <br />EMPLOYEE #:�3 Z <br />DATE: t of <br />ASSIGNED TO: C �i��S <br />EMPLOYEE #: ,/ 'l - <br />DATE: () U C <br />Date Service Completed (if already completed): <br />SERVICE CODE: /C1^ V <br />P I E: L3C <br />Fee Amount: <br />Amount Paid !� D --[Paymentl <br />Date <br />`t> <br />Payment Type S <br />Invoice # <br />Check # ` �a�l(� <br />Received By: <br />EHD 48-02-025 `` °� �1 j SR FORM (Golden Rod) <br />REVISED 11/17/2003 ' <br />3�5,� <br />