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2-U1 <br />SAN JOAQA* COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />PHONE -y EXT. <br />1 <br />fos"7 <br />EMPLOYEE #: 3 Z <br />Szoo (C12'cP`;5 <br />OWNER/ OPERATOR <br />( ) <br />CITY 5IMWIR <br />u C <br />t <br />SERVICE CODE: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Fee Amount: <br />Amount Paid <br />3 <br />.T <br />l <br />5 a� <br />Payment Type <br />Invoice # <br />SITE ADDRESS <br />Check # ! SV2,S�- <br />Received By: <br />1153-769 <br />Street Number <br />Direction <br />Street Nam <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />E-\ r. <br />APN # <br />LAND USE APPLICATION # <br />(� % <br />) G <br />PHONE#2 <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE -y EXT. <br />1 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: 3 Z <br />FAX# <br />ASSIGNED TO: <br />( ) <br />CITY 5IMWIR <br />STATE CA <br />ZIP T52M <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: m l��►IQXV DATE: (Yi+,a({ja21 - 211 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT E) { (}���X(E�WT` `& <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 tome or my representative. <br />TYPE OF SERVICE REQUESTED: — <br />COMMENTS: <br />ACCEPTED BY: �+� LC ✓� I eiA- <br />EMPLOYEE #: 3 Z <br />DATE: �+ <br />ASSIGNED TO: <br />EMPLOYEE <br />DATE: cJ"Z� l <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: (� <br />Fee Amount: <br />Amount Paid <br />3 <br />Payment Date <br />5 a� <br />Payment Type <br />Invoice # <br />Check # ! SV2,S�- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />