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SAN JOAQUIW COUNTY ENVIRONMENTAL HEALTH SARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />CHECK if BILLING ADDRESS® <br />1M I PGt.M <br />p. <br />cL <br />QVfNER /OPE OR <br />CHECK if BILLING ADDRESS <br />j�d.s e <br />F cILnY NAME <br />FAX # <br />SITE ADDRESS1-0 <br />(� iiSVeber Direction <br />VeetAemB Ci Z1 Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />PIE: <br />Fee Amount: <br />Street Number <br />sweet Nam <br />CITY <br />STATE Zip <br />PHONE #1 ExT• <br />APN # <br />Check # <br />LAND USE APPLICATION # <br />PHONE R EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REOUESTOR <br />REQUESTORQi�4- <br />l ` <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />p. <br />cL <br />PHONE # <br />_ �' <br />HOME o MAILI ADDRESS <br />ASSIGNED TO: <br />FAX # <br />DATE: <br />CITY % 1 a <br />Date Service Completed (if already completed): <br />STATE <br />zip <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 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: / �-� DATE: l0 --1 o —k <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT Is not the BILLING PARTY. proof of authorization to Sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ranresent;tive. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: L� iliLe�s`LiM c t.Jcvt `�1' i�JY^ <br />ova., vxq, ooA*Q cj-nd �a irL <br />Q�' Cd.� lfJ2 i <br />r- W'" Q� 7 <br />p. <br />cL <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17108 <br />