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SAN JOAQUI>" COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />HOME or MAILING ADDRESS <br />-3-70 IIAAe Bolo <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY L 6 D 1 <br />STATE �f^ ZIP QS.2'-1 d <br />SITE ADDRESS ¢ <br />Sheet Number <br />Direction <br />G(7 0,3 G <br />Street Name <br />� <br />c1 <br />get <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE#: 73apo <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />SERVICE CODE:S <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR ", b <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME // <br />r <br />COMMENTS: vo-B <br />PHONE# _y_), EXT. <br />) ` <br />HOME or MAILING ADDRESS <br />-3-70 IIAAe Bolo <br />FAX # <br />CITY L 6 D 1 <br />STATE �f^ ZIP QS.2'-1 d <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 this application and that rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA_IEand F RAL IaWS. _ / I <br />APPLICANT'SSIGNATURFl DATE: /YO <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR{MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLICANT is not the B7LLlNG PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />TYPE OF SERVICE REQUESTED: <br />C <br />COMMENTS: vo-B <br />REC (VED <br />gg 14 2009 <br />SUN COUNTY <br />�IFIONM T7 ,LNT <br />tE <br />HF�ALTH DEPART <br />ACCEPTED BY: <br />EMPLOYEE#: 73apo <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: 6 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:S <br />a Z <br />PIE: D <br />Fee Amount: <br />Amount Paid <br />O <br />Payment Date .S <br />Payment Type `� <br />Invoice # <br />Check # q () � S <br />1 Received By: NT— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />