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�'s <br />Kickth <br />8AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />t - 3q 33 SERVICE REQUEST <br />Type of Bu ' ess or Pr perry <br />FACILITY ID # <br /># <br />SERVICE REQUESTtu <br />BUSINESS NC ) <br />�• <br />p ) <br />OWNER /ERAT <br />A <br />CHECK If BILLING ADDRESS <br />tti& <br />FACILITY NAME - j * / <br />1 l� <br />SAN JOAQUIN COUNTY <br />SITE ADDRESS <br />Q. <br />� <br />StreetNuml; DI^ <br />Stree{Name I ' Gotle <br />HOME or MAILI ADDRESS (If Different from Site Address)s/� <br />Street Number <br />�/ / "�'+ i. "-Street Na \' <br />CITY , , <br />STATE C` ZIP <br />PHONE #1 ExT• <br />APN # <br />ASSIGNED TO: <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />X6 CONTRACTOR / SERVICE REQUESTOR <br />REQUEST O } ` <br />CHECK if BILLING ADDRESS <br />BUSINESS NC ) <br />�• <br />p ) <br />401-63 ,r7 ExT. <br />t'AME <br />HOME or MAILING ADDRESS <br />AN 0 5 7006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />CITY / <br />STATE <br />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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa ds, tATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ 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, 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 PAYMand at e same time it is <br />provided to me or my representative. <br />mrnCl\/Crl <br />EHD 48-02-025 SR FORM (Golden Rod) ' <br />REVISED 11/17/2003 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />AN 0 5 7006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: �� <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #:a <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: J° <br />Amount Paid <br />�* Z7 9 v D <br />Payment Date V p (o <br />Payment Type <br />Invoice # <br />Check #10 1�5 <br />Received By: <br />Vf <br />EHD 48-02-025 SR FORM (Golden Rod) ' <br />REVISED 11/17/2003 <br />