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SAN JOAQU16OUNTY ENVIRONMENTAL HEALT*' ARTMENT <br />SERVICE REQUEST <br />e of Business or Property <br />iINESS NAME <br />FACILITY ID # <br />NE Or MAILING ADDRESS <br />�( ( ('STATE <br /># <br />IC7417-�i�"� <br />—7q3 <br />�SERVICE <br />))REQUEST <br />NER /OPERATOR <br />JOAQUIN COUNTY <br />.► <br />if ADDRESS <br />UuTY <br />�^_ C <br />`(/►'\ <br />RUSH <br />CHECK BILLING <br />NAME <br />ACCEPTED BY: ( �, i=t ✓L <br />EMPLOYEE #: -2-( <br />DATE: <br />ASSIGNED TO:(J,� <br />EMPLOYEE #: �2— <br />re <br />DATE: <br />Date Service Completed (if alrea y completed): <br />-T <br />SERVICE CODE: 4� <br />P 1 E: C4 <br />Fee Amount: LFA Z. �-tj <br />r <br />Street NumbeDirection <br />Payment Date <br />treet Name <br />C <br />Zi CodeADDRESS <br />IE or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />r <br />STATE ZIP <br />NE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />NE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />QUESTOR <br />CHECK if BILLING ADDRES <br />v t <br />iINESS NAME <br />ST <br />PH # E. <br />aL <br />NE Or MAILING ADDRESS <br />�( ( ('STATE <br />Filit, U) p C—C' <br />y _ ZIP <br />,LING CKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />nowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />tctivity will be billed to me or my business as identified on this form. <br />so certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />LINTY Ordinance Codes9not <br />STATE and FEDERAL laws. <br />PLICANT'S SIGNAT DATE: / <br />)PEATY /BUSINESS OWNEPERATOR AGER ❑ OTHER AUTHORIZED AGE <br />If APPLICANILLING PARTY, proof of authorization to sign is requi d Titte <br />ITHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />we site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />)rmation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />vided to me or my representative. <br />TYPE OF SERVICE REQUESTED: (,(_S T <br />o� 1'` O P I T <br />COMMENTS: <br />21 2008 <br />. <br />R <br />JOAQUIN COUNTY <br />.► <br />SAN <br />ENVIRONMENTAL <br />DEPARTMENT <br />HM-fH <br />ACCEPTED BY: ( �, i=t ✓L <br />EMPLOYEE #: -2-( <br />DATE: <br />ASSIGNED TO:(J,� <br />EMPLOYEE #: �2— <br />re <br />DATE: <br />Date Service Completed (if alrea y completed): <br />SERVICE CODE: 4� <br />P 1 E: C4 <br />Fee Amount: LFA Z. �-tj <br />Amount Paid Q t£-1 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # I Zj <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />