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SAN JOAQUP" "OUNTY ENVIRONMENTAL HEALTitEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />o <br />SERVICE REQUEST # <br />4005`793q <br />OWNER / OPERATOR <br />HOME or MAILING NDRE4S <br />CHECK If BILLING ADDRESS 13 <br />FACILITY NAME <br />CITY / - ,9,9d6r1 0— , J <br />IL4 O. <br />ZIP <br />SITE ADDRESS <br />/ 3 Street Number <br />Direction <br />Street Name <br />CIt <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />EMPLOYEE#: <br />Street Name <br />CITY <br />ASSIGNED TO: <br />STATE ZIP <br />PHONE #I <br />EXT. <br />DATE: <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />Exr. <br />PIE: O <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />49,1 O <br />PHONE# <br />El, <br />HOME or MAILING NDRE4S <br />FAX# <br />CITY / - ,9,9d6r1 0— , J <br />STATE <br />ZIP <br />PM <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, RAL laws. p <br />APPLICANT'S SIGNA _-� DATE: 2�/7 — o <br />PROPERTY/ BUSINESS OWN OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLt Tis not the B/LLLVG PARTP 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. <br />TYPE OF SERVICE REQUESTED: <br />PgYM <br />COMMENTS:I�IEpIpQ <br />HIN co <br />PkNN DO <br />p�EN <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: - / <br />ASSIGNED TO: <br />EMPLOYEE #: 'Z <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Z� <br />PIE: O <br />Fee Amount: <br />( <br />Amount Paid ` O <br />Payment Date ( l <br />Payment Type <br />✓ <br />Invoice # <br />Check # /l <br />Received By: ��— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />