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- • i- - <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property /�fyees pyo <br />�c�r�r <br />FACILITY ID <br />SERVICE REQUEST # <br />`7 <br />,?.Wee <br />3y-,"- O'PA 2 <br />si?-O v S G Gl <br />FAX # <br />(-2D V,64 - 3074 <br />CITYAAe�, <br />STATEGp ZIP ���/ <br />EMPLOYEE #: zltSB <br />OWNS�/ /OPERATOR <br />if BILLING ADDRESS <br />CODE: Se � <br />FACILITY NAME <br />4/41'A' <br />P i E: !/ VOC <br />SITE ADDRESS <br />Amount Paid <br />Payment Date <br />Payment Type --5 R % J <br />r <br />Check # <br />Received By: <br />!JStreet Number <br />Directiontreet <br />Name <br />Ci <br />Zi Cod <br />HOME or//M�� AILING ADDRESS (If Different from Site Address) <br />P'/ -x a %Q <br />Street Number <br />Street Name <br />CITY <br />S c�� 7e.„ <br />STATE ZIP <br />4W <br />PHONE #1 EXT. <br />PN* <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CgDE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />09 C CHECK if BILLING ADDRESS E] <br />BUSINESS NAME <br />COMMENTS: 3117/09 _�bkdC*'C. �•t�� <br />1p"tides - 3 <br />PHOINNEE #" EXT. <br />"W�e'y - 30 /6' <br />HOME or MAILING ADDRESS <br />- D. Ax /9/o <br />ACCEPTED BY: �(L <br />FAX # <br />(-2D V,64 - 3074 <br />CITYAAe�, <br />STATEGp 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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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: G! icc J / �aii "t'< ✓ <br />COMMENTS: 3117/09 _�bkdC*'C. �•t�� <br />1p"tides - 3 <br />_ �G�r�' <br />ACCEPTED BY: �(L <br />EMPLOYEE #: <br />DATE: J/X3 fj J <br />ASSIGNED TO: ��..� tom. <br />EMPLOYEE #: zltSB <br />DATE: <br />Date Service Completed (if already Completed):SERVICE <br />CODE: Se � <br />P i E: !/ VOC <br />Fee Amount: s2� <br />Amount Paid <br />Payment Date <br />Payment Type --5 R % J <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />