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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />do. , SERVICE REQUEST <br />Type of Business or Property <br />Service station <br />BUSINESS NAME <br />FACILITY ID # <br />U, r <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />CITY ``Cl-� STATE C _. ZIP �" y <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME - <br />ASSIGNED TO: <br />tT— <br />SITE ADDRESS <br />Street Number Direction <br />` . \i <br />Street Name <br />++ '' <br />` � 1 0� <br />city_Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />reet Number <br />Street Name <br />CITY <br />Fee Amount: <br />STATE ZIP <br />PHONE #1 <br />( ) <br />SBD <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />k., CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />11 <br />U, r <br />HOME or MAILING ADDRESS (� , <br />k <br />CITY ``Cl-� STATE C _. ZIP �" y <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 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 require Tide <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 />nrovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />- <br />c I= C E I V E D <br />MAR 18 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />` V I <br />EMPLOYEE #: ( .L <br />DATE: 3 r (1 <br />ASSIGNED TO: <br />tT— <br />EMPLOYEE #: ( ',4 L Z- <br />DATE: -3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: i C�& <br />P I E: 2,3f <br />Fee Amount: <br />d <br />Amount Paid <br />SBD <br />Payment Date / !' <br />Payment Type <br />Invoice # <br />Check # l <br />Keceived By: <br />EHD 48-02-025, SFiQFtM (olde*n Rtii) `' <br />REVISED 11117/2003 <br />