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SAN JOAQU&IOUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME Or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />lVa� <br />AN <br />j eP,p <br />S"o &S1 F/ <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME � I � � <br />G <br />\ � ��--�� DY - <br />1%,0A <br />H�'�R Q j, <br />SITE ADDRESS <br />l I vv <br />�/A ( <br />lll��� <br />I <br />Street Number <br />Direction <br />Street Name <br />ASSIGNED TO: <br />CVit\ <br />ZID Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />'Street <br />DATE: LS <br />Street Number <br />Nam <br />CITYD A � <br />P / E: Z 3 I/ <br />STATE � ZIP <br />PHONE #t EXT. <br />(2c��1 l SSS <br />Amount Paid <br />APN # <br />0G <br />LAND USE APPLICATION # <br />PHONE#2 E., <br />(2 1 3 $ 5 <br />Payment Type- <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME Or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specifi ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business' a identifi o this form. <br />I also certify that I have prepared this applicat n and that th work to e performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT and FERE aws. <br />In c/ <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNERP�— OP TOR / 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 />Co tJ ©,^-) <br />PAY iF <br />COMMENTS: <br />lVa� <br />AN <br />2 5ZO9 <br />�` <br />1%,0A <br />H�'�R Q j, <br />ACCEPTED BY: <br />D L C U <br />EMPLOYEE M <br />DATE: Z S /2. - <br />ASSIGNED TO: <br />C AC 4 6 CT- <br />EMPLOYEE M 14 <br />-,-7�— <br />DATE: LS <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0 (e i <br />i <br />P / E: Z 3 I/ <br />Fee Amount: <br />/ ZS. �� <br />Amount Paid <br />��� �'�' <br />Payment Date <br />Payment Type- <br />S <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 ( ' Q� ' `� SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />