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SAN JOAQU N COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r6�� <br />FACILITY ID # <br />SERVICE REQUEST # <br />ACCEPTED <br />� _^ 1 _ <br />r lT <br />PHONE # I � � � EXT. <br />HOME Or G DDR <br />EMPLOYEE #: ?� , DATE: <br />FAX# <br />1 L G <br />CITY <br />OWNER / PERATOR <br />\ - <br />►) 1 <br />Fee Amount: 3�/ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME , <br />Payment Date <br />Payment Type <br />�,` `� <br />V <br />SITE�D�S <br />Lo <br />�V <br />Vet <br />� <br />` 5,24-6 <br />Street Number <br />Direction <br />"` '�A <br />e <br />Ci <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />-Zip <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHO N 1 Exr, <br />AF N # <br />03 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT f _ <br />ILOC7 CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE <br />1 , <br />V� <br />r6�� <br />CHECK If BILLING ADDRESS <br />BUSINESS NA <br />ACCEPTED <br />� _^ 1 _ <br />r lT <br />PHONE # I � � � EXT. <br />HOME Or G DDR <br />EMPLOYEE #: ?� , DATE: <br />FAX# <br />1 L G <br />CITY <br />SERVICE CODE: �ji' <br />STATE ZIPlSt <br />BILLING ACKNOWLEDGEMENT: 1, 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 I ws. <br />APPLICANT'S SIGNATUR � `- DATE: <br />lam- I <br />PROPERTY / BUSINESS OWNERERA OR S MANAGER ❑ OTHER AUTHORIZED A(;ENT ❑ <br />if APPLICANT is not the B/[ LLNfG 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JAN 19 2011 <br />ENVIRONMENTAL HEALTH <br />ACCEPTED <br />EMPLOYEE #: <br />ASSIGNED TO: t1 t ' '� �r�` <br />EMPLOYEE #: ?� , DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: �ji' <br />P / E��� <br />Fee Amount: 3�/ <br />Amount Paid <br />Payment Date <br />Payment Type <br />Tlnvoice�#' <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />