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SAN JOAQ000UNTY ENVIRONMENTAL HEALTIOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE # EXT. <br />HOMEO MAILI ADDRESS <br />c 4a] <br />< Z)Zw-) q 171 Ir <br />VN, IP <br />STATE ZIP q t—�S-c <br />-a <br />ER / OPER <br />1011 <br />CHECK If BILLING ADDRESS <br />F CILITY NAME <br />AL E <br />S C' cL< <br />EMPLOYEE M <br />SITE ADDRESS ,p ( <br />Date Service Completed (if already completed): <br />SERVICE CODE: "1, <br />P / E: 3L <br />t7 dee PGber <br />Direction <br />39 p9 <br />Street Name <br />CiTZip <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />BIDS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� Jy " <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME�•t� <br />COMMENTS: -6Z nQ�A-64- t�� oY� <br />Cx - d mea <br />PHONE # EXT. <br />HOMEO MAILI ADDRESS <br />i eL. <br />FAX # <br />CITY % �,(J <br />STATE ZIP q t—�S-c <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 />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 an FEDERAL laws. <br />APPLICANT'S SIGNATURE:4 ' DATE: o —k S_ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR rMANAGFR ❑ OTHER AUTHORIZED AGENT 0 <br />If APPLICANT Is not the BILLING PARTY. proof of authorization to sign i3 required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: �K- 1 T (� -A <br />COMMENTS: -6Z nQ�A-64- t�� oY� <br />Cx - d mea <br />sie dIJ� <br />-' W/ OA <br />qi c <br />7 <br />i eL. <br />t V+ <br />RECEIVED D <br />JUN 18 2035 <br />SAN JOAQUIN <br />ACCEPTED BY: ��sa � <br />EMPLOYEE #: <br />AL E <br />ASSIGNED TO:N\tinu0 <br />EMPLOYEE M <br />DATE: t _ <br />Date Service Completed (if already completed): <br />SERVICE CODE: "1, <br />P / E: 3L <br />Fee Amount: �� <br />Amount Paid <br />39 p9 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />