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SAN JOAQUI" COUNTY ENVIRONMENTAL HEALTINEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />ACCEPTED BY: 0, R mt -m <br />SERVICE REQUEST # <br />EXT' <br />8' �6 <br />HOME or MAILING ADDR <br />o 'ii1a�n <br />�e - <br />FAx <br />( /4) <br />8 <br />15ko b `2-7 07 <br />STATE may„ <br />ZIP 9s&3 <br />SERVICE CODE: <br />P I E: 7 <br />Fee Amount: •''� <br />�b <br />OWNER / OPERATOR <br />Payment Date 7 <br />Payment Type V <br />Invoice # <br />Check # �Cl <br />R ceived By: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />[ 1$ <br />e r+o <br />^ '54r, <br />06 <br />SITE ADDRESS <br />14-6,14 <br />/_m?3 <br />Jj6 G�c <br />J Street Number <br />Direction <br />SteGt�Name <br />Cit <br />Zi 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 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION ODE <br />CONTRACTOR / SERVICE REQUESTOR U <br />REQUESTOR / <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />ACCEPTED BY: 0, R mt -m <br />PH E# <br />EXT' <br />8' �6 <br />HOME or MAILING ADDR <br />o 'ii1a�n <br />�e - <br />FAx <br />( /4) <br />8 <br />CITY V x^74 <br />STATE may„ <br />ZIP 9s&3 <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 law . <br />APPLICANT'S SIGNATURE: DATE:/�✓� <br />PROPERTY/ BUSINESS OWNER❑O TOR / MANAGER OTHER AUTHORIZED AGENT <br />If APPLICANT is not th ILLING 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. DAvuF-NT <br />TYPE OF SERVICE REQUESTED: J /n YP»-el-l-"ECEI <br />er E® <br />COMMENTS: <br />OCT 17 2013 <br />SAN JOAQUIN COU <br />ENVROMENTALNW <br />HEALTH DEPARTME'T <br />ACCEPTED BY: 0, R mt -m <br />EMPLOYEE#: n <br />v <br />DATE: (6 ' <br />ASSIGNED TO: V` IA <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P I E: 7 <br />Fee Amount: •''� <br />Amount Paid <br />��' �f� --- <br />Payment Date 7 <br />Payment Type V <br />Invoice # <br />Check # �Cl <br />R ceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />