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l <br />SAN JOAQUIN (:OUNTY ENVIRONMENTAL HEALTH llEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />//'� � CHECK if BILLING ADDRESS IM <br />FACILITY ID # <br />Y � <br />("�Y 4s <br />SERVICE REQUEST # <br />S' <br />PHONE # EXT. <br />IZA <br />7 <br />FAX# <br />OWNER / OPERATOR <br />STATE Zip <br />ACCEPTED BY: <br />� •� <br />7 <br />DATE: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME mit e <br />DATE: /� D <br />Date Service Completed (if already completed): <br />SITE ADDRESS <br />�n({iCl%�� �C <lY� %� �� <br />Amount Paid <br />�t <br />Type � <br />FL 03 Street Number <br />Direction <br />fCh5eck# <br />LLQ •_ ;ba- <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <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 />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j// r_�` Ja ��� /�E` <br />:G C(�tC Sfy�UiCX'S <br />//'� � CHECK if BILLING ADDRESS IM <br />c cl mol E' <br />("�Y 4s <br />BUSINESS NAME <br />bre6 55ZyC <br />RECEIVED <br />PHONE # EXT. <br />IZA <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY <br />STATE Zip <br />13-'Z <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 <br />or 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: all J> �- 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 and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JUL 17 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />H - <br />ACCEPTED BY: <br />EMPLOYEE #: i.QQ <br />'3 V <br />DATE: <br />ASSIGNED TO: G�✓VJ <br />EMPLOYEE #: qx <br />DATE: /� D <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />Fee Amount: <br />Amount Paid <br />Payment Date .Z -7Payment <br />Type � <br />Invoice # <br />fCh5eck# <br />LLQ •_ ;ba- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />