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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MFI��VLIC-' <br />-F <br />PHONE# Er' <br />FACILITY ID # <br />i 4i�s <br />FAX# <br />SERVICE REQUEST # <br />5 <br />OWNER / OPERATOR <br />L1 �. <br />1.V <br />NLGEIVED <br />iAN 16 201 <br />SAN JOAQUIN COUNTY <br />ENVINONMENTAL <br />IIEALTN DEPARTMENT <br />ACCEPTED BY: CLk,r(HC0 LQ <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME <br />O <br />ASSIGNED TO: <br />EMPLOYEE#: <br />SITE ADDRESS <br />Street Number I <br />DI cticn r"W,l t /'�' t <br />ams <br />SERVICE CODE: 5-113 <br />I <br />PIE:IF <br />212 atl0 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Payment Date <br />Stroet Name <br />Payment Type <br />CITY <br />Check # 7i ,i <br />2 <br />STATE Zip <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />—�- CHECK If BILLING ADDRESS 13 <br />BUSINESS NAME <br />PHONE# Er' <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE 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 <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 JOAQtma <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ^ ^ <br />APPLICANT'S SIGNATURE:(Li to �L i! DATE: <br />Poe <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ 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 ENvTRONMENTAL 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: tWVL— <br />PAYMENT <br />COMMENTS: <br />NLGEIVED <br />iAN 16 201 <br />SAN JOAQUIN COUNTY <br />ENVINONMENTAL <br />IIEALTN DEPARTMENT <br />ACCEPTED BY: CLk,r(HC0 LQ <br />EMPLOYEE #: <br />DATE: _ 1 — <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed in already completed): <br />SERVICE CODE: 5-113 <br />PIE:IF <br />Fee Amount: � �. <br />Amount Paid <br />SZ — <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 7i ,i <br />2 <br />Received By: <br />EHD 48-02.025 C R.Y..e LC f 1 C-Ctt— SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />