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SAN JOAQUIN#UNTY ENVIRONMENTAL HEALTH�EPARTMENT <br />SERVICE REQUEST <br />Type of Busine or Property <br />t <br />FACILITX ID # <br />TOV 02Z- 3 Z <br />SERVICE REQUEST # <br />aseeo4la-2a. <br />OW4R / OPERATOR -4/)&0VW <br />AMAA�...._CHECK <br />If BILLING ADDRESS❑ <br />p , _'/ <br />FACILITY NAME (� SMO.- <br />EMPLOYEE #: <br />A <br />SITE ADDRESS _120 <br />&treet Number <br />on <br />Directit <br />�l /h <br />t Nam <br />DATE: <br />��z Cude,9 <br />HOME or MAILING ADDRESS (If ifferent f m Site Address) <br />r <br />Street Number <br />Street Name <br />CITY <br />Fee Amount: <br />7a, STATE ZIR <br />P QNE#l) ExT. <br />Payment Type - ' <br />APN # <br />Check # b 4' <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Sia) —� <br />BOS DISTRICT <br />TLOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO ItCHECK if BILLING ADDRESS <br />BUSINESS NAME ` <br />T <br />HOME or MAIu DDRESS--, - <br />bl <br />CITY ' ) STAT ZIP%j� <br />P2 <br />BILLING CKNOWLEDGEMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard , TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:1L.)�AjDATE: C <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L <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 />vrovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />RE <br />MAy - 9 Zoos <br />uNv <br />SA eNNJIRONM TMEtir <br />LTH DEPA <br />1-DATE:7� <br />ACCEPTED B <br />EMPLOYEE #: <br />ASSIGNED 1 <br />EMPLOYEE #: <br />DATE: <br />Date Servic Completed (if already completed): <br />SERVICE CODE: <br />PIE: _a <br />Fee Amount: <br />Amount Paid is <br />Payment Date I p <-- <br />Payment Type - ' <br />Invoice # <br />Check # b 4' <br />Received By: �� <br />EHD 48-02-025oll e2od) <br />REVISED 11/17/2003 <br />