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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALT*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />C/ <br />FAWD?7��3 <br />CHECK if BILLING ADDRESS❑ <br />SR -00'7908(P <br />OWNER / OPERATOR <br />PHONE # <br />❑ <br />• � <br />ASSIGNED TO: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAI ADDP.ESS <br />DATE: /'E' , -Z <br />(J <br />SITE ADDRESS <br />CITY, <br />STATE / 4 <br />ZIP L <br />Street Number Direction <br />s <br />Street Name <br />Invoice # <br />Cit <br />Zi Code <br />HOME or AILING AD ESS (If Different from Site Address) <br />Rec ved By: <br />Street Number <br />Street Name <br />CITY/ ,o <br />–elPHONE <br />$TATE/+ . ZIP <br />#'I EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(Z16,O� <br />1[ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: ^� j _„ Ica <br />Vr.� 1 <br />orJ���h,� ��, - <br />CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME <br />PHONE # <br />EXT. <br />DATE: / ?-�/' <br />C� <br />ASSIGNED TO: <br />( )3,6F% <br />✓ <br />HOME or MAI ADDP.ESS <br />DATE: /'E' , -Z <br />(J <br />FAX# <br />CITY, <br />STATE / 4 <br />ZIP L <br />Amount P ' Y?b 0 <br />s <br />Payment Type <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, STAP andJDERAL la s <br />APPLICANT'S SIGNATURE: _ / DATE: <br />PROPERTY / BUSINESS OWNE PERA MI6/ MAN k6d[I THER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is o eBILLINGPARTY proof of horizatim: 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. A-& <br />TYPE OF SERVICE REQUESTED:U 5 7— <br />COMMENTS: ^� j _„ Ica <br />Vr.� 1 <br />orJ���h,� ��, - <br />�qN J��Nvr <br />ZZ��FO <br />hFq� y,9oMNco��6 <br />g%T, HyY <br />TMF <br />ACCEPTED BY: tF A <br />EMPLOYEE M <br />DATE: / ?-�/' <br />C� <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: /'E' , -Z <br />(J <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P /,E: 'Z <br />Fee Amount: 2J <br />Amount P ' Y?b 0 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # /L3 <br />Rec ved By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />