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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTH OARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />AVS �,/; Env 1 <br />F CILITY ID # <br />SERVICE REQUEST # <br />GG <br />r <br />PHQNE#_ EXT. <br />HOME or MAILING ADDRES$� <br />r <br />OWNER /OPE OR <br />Fq# <br />CHECK if BILLING O <br />c-,'(` <br />STATE zip <br />J C� <br />ADDRESS <br />FACILITY NAME Q <br />oea <br />Payment Date <br />cc) � C""60AIL <br />C 1 y i I 1 C' `Cr <br />Invoice # <br />SITE ADDRESS i Ll C11', <br />'Street <br />Received By <br />, J� w �� SS <br />C1 1 <br />Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />QoT - - 9112, <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />AVS �,/; Env 1 <br />CHECK if BILLING ADDRES, <br />BUSINESS (NAME <br />Co <br />EMPLOYEE #: <br />�l <br />PHQNE#_ EXT. <br />HOME or MAILING ADDRES$� <br />1 , C GL <br />W <br />DATE: <br />Fq# <br />CITY Vo C� -c> <br />SERVICE CODE: 6 <br />STATE zip <br />J C� <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, Standart, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 1.2 <br />PROPERTY/ BUSINESS OWNER ❑ PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT i not th BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RE FEA 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. Al 17 1*7 <br />TYPE OF SERVICE REQUESTED: S <br />AVS �,/; Env 1 <br />COMMENTS: <br />DEC - 7 200 <br />SAN JOAQUIN COUNn <br />ENVIRONME 4TALT <br />DEPAR <br />ACCEPTED BY: <br />EMPLOYEE #: <br />�l <br />ASSIGNED TO: AM <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed . <br />SERVICE CODE: 6 <br />1 PIE: <br />Fee Amount: <br />Amount Paid <br />oea <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod <br />