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SAN JOAQUICOUNTY ENVIRONMENTAL HEALTH OEIPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME � <br />FACILITY ID # <br />SERVICE REQUEST # <br />0 w v- ' <br />t -art <br />ova <br />OWNER / OPERATOR <br />S <br />TM 0E <br />H <br />CHECK If BILLING AnnRFSSff <br />FACILITY NAME 2 , 'A <br />�p'{T <br />EMPLOYEE #: <br />SITE ADDRESS <br />I <br />EMPLOYEE #: <br />DATE: */4 <br />2 Street Number <br />Dib ion <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />3' S� <br />1 PaymeA <br />Date <br />i <br />Street Number <br />Street Name <br />CITY <br />Invoice # <br />STATE ZIP <br />Check # --)-0-71 <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE 42 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME � <br />PHONE # � .. � O EXT; <br />HOME or MAILING ADDRESS ,^ - <br />FAx# <br />ZIP4q <br />CITY STATE CA <br />BILLING ACKNOWLEDGEMENT: 1, 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. I <br />APPLICANT'S SIGNATURE: Dt rF �j DATE: /-7 4,1 <br />p4 <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR/1\IANAGER ❑ OTHERAUTIIORIZEDAGENT tYnCW�xnw <br />If.4PPL/CANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZA'T'ION 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. _ _%,rI Af:NIT <br />TYPE OF SERVICE REQUESTED: UIST <br />ZE=025T <br />gEcENED <br />COMMENTS: <br />�w^ Is 2�®� <br />COUNT <br />QUINAqWEN <br />S <br />TM 0E <br />H <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: */4 <br />Date Service Completed (if already completed):SERVICE <br />CODE: <br />Fee Amount: l da <br />Amount Paid <br />3' S� <br />1 PaymeA <br />Date <br />i <br />Payment Type <br />Invoice # <br />Check # --)-0-71 <br />1 Received By: zl-� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />