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SAN JOAQUI UNTY ENVIRONMENTAL HEALTH <br />SERVICE REQUEST <br />HLGHVEL) <br />ARTMENT <br />NOV 0 9 2011) <br />A e -77 - <br />Type of Business or Property <br />n <br />\Aa u <br />CHECK If BILLING ADDRESS <br />ID # <br />SERV <br />`1 V1 <br />PHONE# , y _ EXT. <br />HOME Or MAILING ADORE <br />%F^�ACILITY <br />EMPLOYEE #: <br />`AX# ) �j l �^ ` t�� <br />OWNER / OPERATOR _. <br />STATE C ZIP 0 "j a <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />V \ <br />SERVICE CODE: L' <br />SQARITE ADDRESS <br />L,` <br />Amount Pai ��(� vt� <br />Payment Date <br />1\0-V nLCIQtCR <br />"` <br />SeeNm <br />tion <br />Check # <br />tre t Name <br />Received By: <br />ZI Coder <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />ii r-1 � <br />L <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />n <br />\Aa u <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME 1 <br />'SQ -,q'\!` <br />`1 V1 <br />PHONE# , y _ EXT. <br />HOME Or MAILING ADORE <br />� <br />EMPLOYEE #: <br />`AX# ) �j l �^ ` t�� <br />CITY \ f� <br />STATE C ZIP 0 "j a <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 ❑ OPERATOR , MANAGER ❑ THER 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. A <br />TYPE OF SERVICE REQUESTED: �; C " �'>, <br />ZMN <br />COMMENTS: FQ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />FIs <br />`1 V1 <br />ti �'R 4, �9 <br />� o MF °oo <br />ACCEPTED BY: Cx, <br />EMPLOYEE #: <br />DATE: I) C <br />ASSIGNED TO: MSI .I <br />EMPLOYEE #: <br />DATE: , <br />Date Service Completed (If already completed): <br />SERVICE CODE: L' <br />PIE: 2-7,� <br />Fee Amount: 3 'C� — <br />Amount Pai ��(� vt� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />.2 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />FIs <br />