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SAN JOAQUIIIZ'OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />- <br />dq <br />CITY3 7'0 L1 /ate, " ' v STATE 8� ZIP � 5. <br />a43 <br />OWN R / OPERATOR <br />CHECK If BILLING ADDRESS <br />pp ,�,� <br />l�l�L�(il. <br />�^-{�7r A� <br />/ 7L `�` <br />-,411a-4-IM <br />FACILITY NAME / <br />SITE ADDRESS <br />}�17��j�}' <br />JZ. Street Number <br />Direction <br />/`^' <br />Street Name <br />v Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Z3L�iC <br />Street Number <br />Street Name <br />CITY <br />l <br />STATE} ZIP <br />PHONE #t EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�I �r-�iv„�e`•� � � CHECK If BILLING ADDRESS 01 <br />BUSINESS NAME <br />PHONE# ExT. <br />- 0 9G7- <br />HOME or MAILING ADDRESS/ y1 <br />25d F Y <br />FAX# <br />dq <br />CITY3 7'0 L1 /ate, " ' v STATE 8� ZIP � 5. <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 a t t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE a FE RAL <br />APPLICANT'S SIGNATURE / DATE: / t% hel' <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule <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 ar1i; at the same time it is <br />provided to me or my representative. „� •q Xk®_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: K• �` <br />a <br />a zoy <br />H�4� <br />�RTMFHT <br />ACCEPTED BY: e ���� EMPLOYEE #: 3 Z DATE: /O / <br />ASSIGNED TO: Q EMPLOYEE #: t� �� DATE: <br />Date Service Completed (if'already completed): SERVICE CODE: ( o �'5 1 <br />Pit: q <br />Fee Amount: 5 a 0O Amount Paid 2 . Payment Date 1 p g 119 <br />Payment Type A,() J 1 Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />