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SAN JOAQLIO-COUNTY ENVIRONMENTAL HEALT0IEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�(� CHECK if BILLING ADDRESS <br />BUSINESS NAME } <br />FACILITY ID # <br />PHONE# EXT. <br />SERVICE REQUEST # <br />0 o 7077 <br />OWNER / OPERATOR (\g <br />QmCHECK <br />STATE ZIP —1 A�51 <br />If BILLING ADDRESS <br />FACILITY NAMEWq' <br />YA <br />-Va � V0 <br />Fee Amount: � <br />Amount Paid U00 00 <br />Payment Date `b/d/) <br />SITE ADDRESS I <br />Street Number <br />J <br />Direction <br />v1r� \ Q1 1 1�'� I V, <br />1 Street Name l <br />Received By: <br />THW�tC <br />Cit <br />T ;J 1 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY t 1 <br />M <br />STATE t ZIP <br />PHONE M ExT• <br />("(02) �-15- 3(p2 <br />APN # -z-7 <br />X22 6 0 - <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �l <br />�(� CHECK if BILLING ADDRESS <br />BUSINESS NAME } <br />�' r[ `'(� (� <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX # <br />CITY �(� <br />STATE ZIP —1 A�51 <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 <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, STATE,and FEDERAL laws. <br />APPLICANT'S SIGNATU DATE: <br />PROPERTY /BUSINESS OWNER❑ R / <br />OPERATOMANAGER 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. �p n <br />TYPE OF SERVICE REQUESTED: 11 `qN <br />v <br />COMMENTS: <br />OCTq (, 3 2014 <br />EM°Aov,N <br />H�q�TH AO y <br />NT <br />ACCEPTED BY: C�ti <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: fd <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E:� <br />Fee Amount: � <br />Amount Paid U00 00 <br />Payment Date `b/d/) <br />Payment Type l <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />