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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />APPROVED BY: <br />OQ9 3&o& <br />EMPLOYEE #: V 3.2 f <br />005'i� 1 :7 7 <br />OWNER / OPERATOR <br />E� Cjjs\- <br />CHECK if BILLING ADDRESS <br />CITY C <br />STATEC,4 zip <br />FACILITY NAME 6Q(,O <br />P i E: Z23. 0 '_ <br />Fee Amount: <br />WOME <br />C- <br />Payment Type <br />-SVNIFName <br />Ci Zi D Code <br />or MAILING ADDRESS (if Different 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 #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS El <br />t,, A <br />APPROVED BY: <br />BUSINESS NAME <br />EMPLOYEE #: V 3.2 f <br />PHONE # ExT. <br />3e <br />HOME or MAILING ADDRESS <br />1 <br />FAx # <br />(2/3 301 15-17 <br />CITY C <br />STATEC,4 zip <br />I— I/ <br />s 11,01 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />ds 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, Standards, STAT OPFE L laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY I BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IDI A 67 <br />IfAPPLICANT 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: u -S'-%.-ry OF 17 RtCIEIVI�--u <br />COMMENTS: <br />V rZ A A Z <br />o 0 <br />MAY 2 7 Z004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE #: V 3.2 f <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: f3-7- <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: lfit` k, -T <br />P i E: Z23. 0 '_ <br />Fee Amount: <br />Amount Paid <br />Payment Date u Lf <br />Payment Type <br />Invoice # <br />Check # ;),33 <br />Received By: <br />SERVICE <br />REVISED 6-5-02 <br />