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SAN JOAQUII UNTY ENVIRONMENTAL HEALTPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />V <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME Q -<�- Q <br />SITE ADDRESS COC ( <br />Strt Number <br />ee <br />C.ra3T <br />I Direction <br />I✓It�r A Y t, <br />Street Name <br />ENVIRONMENTAL <br />/' C- ke_C CA,C���j <br />Cit <br />6 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />670 64 C 'filt Street Number <br />ACCEPTED BY: <br />Street Name <br />CITY / <br />w <br />DATE: <br />STATE(,) 1 ZIP <br />r J <br />Exr. <br />PHONE #'I <br />( qc 7o 3 Err L <br />EMPLOYEE #: <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />SERVICE CODE: O <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />PHONE# ExT. <br />( ) <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY 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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDEI AL laws. <br />APPLICANT'SSIGNATUREk <br />1C. <br />� �^"�— DATE: <br />—r <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ k%/y <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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />.RECEIVED <br />COMMENTS: <br />CLEC 2 2 2008 <br />✓�it/ DVI���� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:� <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: O <br />P I E. -Z' <br />Fee Amount: <br />Amount Paid <br />_ <br />Payment Date <br />�'2- 1-� <br />Payment Type <br />Invoice # <br />Check # �cJ b <br />Received By: —e, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />