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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# EZT. <br />I <br />FACILITY ID # <br />� G�oate� <br />FAx# <br />SERVICE REQUEST # <br />gf� po76a�� <br />OWNER/OPERATOR <br />2 2 TO <br />SAN,, <br />CHECK If BILLING ADDRESS <br />FACILITY NAME C� <br />er <br />Qu <br />A +5 <br />SITE ADDD ESS <br />11 Street Number Direction <br />- i tl,hTh�liJ% +� h <br />v Stre¢i Name <br />S hi(.OW1 <br />CI <br />5✓ F� <br />zip Cotla <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />Street Number <br />Street Name <br />CITY <br />Amount Pai <br />�'7g b D <br />STATE zip <br />PHONE#1 <br />T' <br />APNIf <br />LAND USE APPLICATION# <br />( ) S <br />PHONE #2 <br />( ) <br />EXT. <br />BIDS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / /1 p CHECK If BILLING ADDRESS <br />fF J V L� <br />BUSINESS NAME <br />PHONE# EZT. <br />I <br />HOME or MAILING ADDRESS /J / , I <br />!w 1 <br />FAx# <br />CITY STATE - zip G1 <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 />also certify that I have prepared this application and that the work to be pert ed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FE ERA WS. <br />APPLICANT'S SIGNATURE: DATE: // <br />PROPERTY / BUSINESS OWNER ❑ OPE TOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof Of authorization to sign Is requi d Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />Q IctV1au C <br />FC <br />COMMENTS: <br />V <br />2 2 TO <br />SAN,, <br />Hf t N CO <br />q r4k <br />F <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: FJ�7J <br />PIE: <br />Fee Amount: 5FT-6cL <br />Amount Pai <br />�'7g b D <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # gj -i <br />Rec ived By.?—,,//S <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />Vr <br />b <br />irry <br />