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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST • <br />Type of Business or Property <br />CHECK If BILLING ADDRE <br />�- <br />BUSINESS NAME <br />FACILITY ID # <br />P N EXT.-- <br />SERVICE REQUEST # <br />CIJAJ)sk�SiL <br />FAX # — <br />) <br />CITY <br />�Y , / , STATE <br />3q -2 --SAO <br />Lt t.Z06 <br />OWNER PERATOR <br />A Coa <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />� YA'02d <br />SITE ADDRESS <br />/ <br />� � <br />Street Number <br />Direction <br />SICr <br />HOME or MAILINGD,DDR�ESS <br />(If Different from Site Address) <br />lel/ <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />3&) _d2, <br />. <br />3l-- -3d <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CZ <br />CONTRACTOR / SERVICE REQUESTOk <br />REQUESTOR <br />CHECK If BILLING ADDRE <br />�- <br />BUSINESS NAME <br />P N EXT.-- <br />HOME or MAILING ADDRESS <br />hi <br />FAX # — <br />) <br />CITY <br />�Y , / , STATE <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 />I also certify that I have prepared this a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. / <br />APPLICANT'S SIGNATURE:im'rf DATE: <� <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ 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 <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 <br />t the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: tA,S%- AiS7-)" r— t-7— <br />COMMENTS: <br />TCOMMENTS:�- <br />0 <br />S�N� <br />N <br />ACCEPTED BY: D L't t/F—t EMPLOYEE #: Q '3 2_( DATE: t( (p r U to <br />ASSIGNED TO: VON Vt—E4- E EMPLOYEE #: 6'3 t % DATE: <br />Date Service Completed (if already completed): SERVICE CODE: i E:.�,3_ 041 <br />Fee Amount: .5�y' vo Amount Paid a S (5-0 Payment Date b <br />Payment Type ✓� Invoice # Check # L \ 3 D lits- Received By: �- <br />EHD 48-02-025 SR FORM "(Golden Rod) ` <br />REVISED 11/17/2003 <br />