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SAN JOAQUIOUNTY ENVIRONMENTAL HEALT""EPARTMENT <br />SERVICE REQUEST <br />TypW Businesso roperty FACILITY ID # SERVICE REQUEST # <br />�AaA O �d -7 -7.5.3 <br />OWNE4 OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME 4Q-4 <br />Q <br />r r r <br />MYIVIEN <br />R T <br />COMMENTS: <br />rTEDDRESS, <br />I <br />��i <br />IIWW, reef Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CIN STATE ZIP <br />PHONE #1) -mo E)". <br />APN # LAND USE APPLICATION # <br />�� <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />REQUESTOR <br />BUSINESS NAME Ek <br />CONTRACTOR / SERVICE REQUESTOR <br />I CHECK if BILLING ADDRESS <br />PHONE# ExT. <br />HOME or MAILING ADDRESS- <br />FAX# <br />fSI U tav <br />(�7) ` 54 <br />CITY STA ZIP '"�� <br />BILLING ACKNOWLED : I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENWRONNmENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared thi pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar s STATE FEDER. aws <br />APPLICANT'S SIGNATURE: I DATE: L/ <br />PROPERTY/ BUSINESS OWNER ❑ 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. r, <br />TYPE OF SERVICE REQUESTED: <br />S <br />MYIVIEN <br />R T <br />COMMENTS: <br />APR 2 6 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: C <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #:L� <br />DATE: <br />Date Service Completed (if already completed : <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />�� '7f '— <br />Payment Date <br />Payment Type <br />Invoice # <br />Check #- g'� U� <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />