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SAN JOAQUI0OUNTY ENVIRONMENTAL HEAL *EPARTMENT <br />SERVICE REQUEST <br />Ty a of Busines r Property FACILITY ID # SERVICE REQUEST # <br />� <br />OWtJIER/OPEM <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME p ^ A.-- _ <br />SITE <br />HOME or MAILING ADDRESS <br />CITY <br />PHONE #1 <br />II) ;2 /3 <br />PHONE 2 EXT. <br />(_ L� - 35 mbbill <br />TE Zip <br />C <br />D USE APPLICATION # <br />BOS DISTRICT 11 LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />S <br />FRA <br />COMMENTS: <br />V <br />HECEIVEp <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />/��}) <br />PHON <br />r j EXT. <br />ENVIRONMENTAL <br />n <br />�z 0 <br />' <br />HOME Or MAILING ADDRESS <br />GUL <br />FAX # <br />DATE: <br />CITY <br />EMPLOYEE #: <br />STATE <br />i <br />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 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 thqap cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandarT la <br />" Z� o� <br />i; APPLICANT'S SIGNATURE: DATE: / <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER ❑ OTIIER AUTIIORIZFD AGENT �— f <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 HEALTiI 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 />S <br />FRA <br />COMMENTS: <br />V <br />HECEIVEp <br />APR 2 6 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />n <br />�z 0 <br />HEALTH DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE #: <br />C <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid : -2 7 le <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # g 1:�;_ <br />Received By: / , <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />1� <br />SERVICE REQUEST FORM <br />