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* SAN JOAQUI� UNTY ENVIRONMENTAL HEALT�SEPARTMENT <br />4b, SERVICE REQUEST <br />—f'au I �ict) G YS-7ur <br />rz <br />Ty p f Business o roperty <br />FACILITY ID # <br />/C-400:3 <br />SERVICE REQUEST # <br />s/�z <br />M: <br />6�� <br />0D5k�e <br />OWN1111 / OPERA O <br />CHECK if BILLING ADDRESS El <br />FACILITY NAME <br />SAN OpAQ1J1N GOUNTY <br />SITE ADDRES���1 <br />r{ / ireet Number <br />cfion <br />DEPARTMENT <br />Street Name <br />r <br />SaUJ <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />e <br />EMPLOYEE #: <br />Street Number <br />ASSIGNED TO: <br />ee e <br />CITY <br />TE <br />zip _ <br />PHONE t ExT. <br />APN # <br />LAND USE APPLICATION # <br />P I E: <br />Fee Amount: <br />Amount Paid <br />PHONE #Z ExT. <br />Payment Date <br />BOS DISTRICT <br />LOCATION CODE <br />CO; --;TRACTOR / SERVICE REQUESTOR <br />REQUESTO CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />h:112 <br />HOME Or MAILING TDDRESSF6-�53 — t L l — <br />CITY /ly ) STATE zip(/,`SD n r -- <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 or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this an <br />hat the work t e performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard , T / <br />APPLICANT'S SIGNATURE:! DATE: 17X41 t <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN <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. oovMENT <br />TYPE OF SERVICE REQUESTED: S <br />�� <br />RECE <br />COMMENTS: <br />� <br />Y <br />1,1N 20 <br />,SIr <br />SAN OpAQ1J1N GOUNTY <br />t11000 1 <br />o �/ �� " <br />DEPARTMENT <br />HEALTH <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: %1-7. (� <br />ASSIGNED TO: <br />C <br />EMPLOYEE #: ✓ r( <br />`� <br />DATE: <br />Date Service Completed (if alrea y completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />$ja �9 D� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # gL� �'� <br />Received By:�; <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�l <br />