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W, <br />SAN JOAQUI#OUNTY ENVIRONMENTAL HEALTT' EPARTMENT <br />SERVICE REQUEST <br />of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />_ <br />SERVICE REQUEST # <br />Gci"2 <br />t, / (� <br />`rf <br />FAx <br />#PA,� 3 L� Z _mid r� 7 <br />sM <br />ER / OP RATOR <br />/x �r\ V�V� <br />ENV;11ONMENTAL <br />CHECK If BILLING ADDRESS <br />Y NAME <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />DDRESSvs <br />(� <br />p r�7 <br />1 <br />��•N�a��/m��'e"""��• <br />LCi <br />PI E: (r f <br />Street Number <br />Direction <br />Street <br />Payment Type ,/t <br />Invoice # <br />Zi Code <br />or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />STATE ZIP <br />#1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />#Z <br />ExT. <br />BOS DISTRICT / <br />'3 47 11 <br />LOCATION CODE <br />a <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \ 44 U I <br />V[J <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME � � r. <br />_ <br />PHONE# � n ^ � ! xT. <br />HOME Or MAILING ADDRESS- n3 b <br />�-( <br />t, / (� <br />`rf <br />FAx <br />#PA,� 3 L� Z _mid r� 7 <br />CITY l Lo <br />;KA <br />STATE ri/i 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 thi lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standates, SIATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: I �' <br />PROPERTY / BUSINESS OWNER ❑ OPERATORIAIANAGER ❑ 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 />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />'pAYMEN <br />TYPE OF SERVICE REQUESTED: <br />_ <br />COMMENTS: <br />AUG 7 2007 <br />I&AN JOAOUIN COUNTY <br />ENV;11ONMENTAL <br />ails ftp ;-=pARTME.Nf <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: �� <br />Date Service Completed (if already completed): <br />r�11DATi <br />SERVICE CODE: 1C' <br />PI E: (r f <br />Fee Amount: Z vb <br />Amount Paid <br />Payment Elate n <br />Payment Type ,/t <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />