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SAN JOAQUIN UOUNTYP, <br />SERVICE0 REQUEST <br />Type of Business or Property <br />�; <br />FACILITY ID # <br />e-ftgm <br />BUSINESS NAME <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />HOME Or MAILING ADDRESS <br />. 0 - 3 /.3.2 S <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY S o C k4ply <br />STATE ZIP <br />SITE ADDRESS <br />® Street Number ; Direction <br />Street Name M, baLina.-viecd <br />ZiggsIdE <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Date Service Completed (if already completed): <br />Street Name <br />CIN <br />I E: q, 3CA <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />� � � <br />LAND USE APPUCATION # <br />PHONE #2 ExT• <br />( ) <br />F+7Invoice <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR e i , r <br />U oc <br />REQUESTOR '/ <br />/ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT' <br />--'' 3 <br />HOME Or MAILING ADDRESS <br />. 0 - 3 /.3.2 S <br />(V� <br />FAX# <br />of) <br />CITY S o C k4ply <br />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 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 JOAQLm <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / AGER ®. OTHER AUTHORIZED AGENT 19 N J Cd .- <br />IfAPPMCANT is not theB1LLINGPARTY 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 availlaabl�, same time it is <br />Drovided to me or my representative, r,,=rt=NE <br />TYPE OF SERVICE REQUESTED: (/i e T 4,r" f— 1 ) <br />"� <br />COMMENTS: <br />G1UlP1 <br />SAN 301AONM �Egr <br />HATH pEPrv' ... <br />ACCEPTED BY: <br />(V� <br />EMPLOYEE#: Da)S <br />DATE: <br />ASSIGNED TO: <br />NvorX Q \A <br />EMPLOYEE #: 1�'7 O <br />DATE: S —7-0 — V7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: Li—P <br />I E: q, 3CA <br />Fee Amount: <br />S006 .0v <br />Amount Paid <br />� � � <br />Payment Date _? j O % <br />Payment Type <br />F+7Invoice <br /># <br />Check # <br />Received By: <br />�;EHD 48-02-025 <br />s s" <br />"ll' <br />REVISED 11/17/2003 <br />