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SAN JOAQUI'"OUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of BuiL <br />si ess or Prop y <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />ikL f� <br />SERVICE REQUEST # <br />2 r <br />OWNER / OP <br />AT <br />I ,� , 1/ � <br />�j <br />CHECK If BILLING ADDRESS iJ <br />FACILITY NAME <br />U' <br />SITE ADDRESS <br />Street Number <br />Q <br />Direction <br />g q <br />l/ t_/ Street Name C <br />i <br />J%�] <br />9��' <br />ZirxCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTO I <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PH NE# ' r EXT. <br />HOME or MAILING ADDRESS <br />a, 1 k1-4 <br />FAX# <br />-W14 <br />CITY <br />,STATE ZIP <br />BILLING ACKNOWLEbGEMENT: 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 app 'c tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S A and(f <br />,EYERAL WS. J <br />APPLICANT'S SIGNATURE: A DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGEN <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Ti rl e <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�at the same time it is <br />provided to me or my representative. pM E� <br />TYPE OF SERVICE REQUESTED:—%�%� F t / R <br />COMMENTS: ty1f / J3�4 y R GOVN"N <br />1\ffik PR, <br />ACCEPTED BY: L t C✓( i+ EMPLOYEE #: 32-1 DATE: A Y <br />ASSIGNED TO: �� 'Gr�� [ .�r/'7 EMPLOYEE #: �� 7>` DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P / E: L, d <br />Fee Amount: ? c,, 0D Amount Paid Payment Date p L <br />Payment Type I Invoice # I Check # �S3c1 I Received By: -7� I <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />