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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTH *ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK P BILLINfI AD®RNiY <br />FACILIfY NAME <br />PHONE #T' <br />SRE ADDRESS <br />Street Number <br />kectlon <br />�`y� f <br />Naw <br />�C <br />G6di' <br />HOME or MAILING ADDRESS (If DFfferent from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE R ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK IF AlkNIARRUM <br />BUSINESS NAME <br />ACCEPTED BY: <br />PHONE #T' <br />EMPLOYEE M <br />DATE: <br />'10 <br />Wk <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) r <br />CITY <br />STATE G ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or pro cific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me o my business 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 EDERAL laws. <br />APPLICANT'S SIGNATURE: -'I- DATE:.0"95 offaelp- <br />PROPERTY / BUSINESS OWNER 11",OPERATOR / MANAGER OTHER AUTHORIZED AGENT_�� <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 to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: �.���:�,� rltJ-�' <br />���� /rs U � �� /���-% --!' j9�%�� • /�/IF �i�7� <br />s t'3 <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />'10 <br />Wk <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />HEAL <br />Date Service Completed (if already completed): <br />SER E CODE: / <br />P I E: <br />Fee Amount: 2 <br />Amount Paid j 2 8s` <br />Payment Date <br />Payment Type ✓ <br />I Invoice # <br />Check # 113-0 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />