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<br />SERVICE REQUEST
<br />Type of Business o/Ar` Property
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<br />CHECK If BILLING ADDRESS
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<br />SERVICE REQUEST #
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<br />Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />Street Number
<br />ASSIGNED TO:
<br />Street Name
<br />CITY
<br />STATE zip
<br />PHONE #1
<br />( 1
<br />Ext.
<br />APN #
<br />Fee Amount: S
<br />LAND USE APPUCATION #
<br />PHONE #2
<br />( 1
<br />Ext
<br />Payment Type
<br />BOS DISTRICT
<br />LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
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<br />REQUESTOR s &,A -AJ
<br />CHECK If BILLING ADDRESS
<br />BUSINESS NAME S//� //v/� % //'��
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<br />COMMENTS: 7/20/0 1— J t� - aaZ ' y S � NS
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<br />CITY c)ii Ck LX FEEL
<br />STATE,, zip W6
<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 lawsAX(_
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<br />APPLICANT'S SIGNATURE: 6/,,d DATE: n
<br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT ® (2 t (led -Ok
<br />If APPLICANT is not theBILLiNGPARTY. proof of authorization to sign is required Title
<br />AUTHORi7ATION 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 Wne time it is
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<br />provided to me or my representative. Pp,N
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<br />TYPE OF SERVICE REQUESTED::
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<br />COMMENTS: 7/20/0 1— J t� - aaZ ' y S � NS
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<br />HEALTH DEPARTMENT
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<br />ACCEPTED BY:
<br />EMPLOYEE #:
<br />DATE:
<br />ASSIGNED TO:
<br />EMPLOYEE P
<br />DATE:
<br />Date Service Completed (if already Completed):
<br />SERVICE CODE: 3,60
<br />P I E: 440
<br />Fee Amount: S
<br />`�
<br />Amount Paid 03 .�-- v o
<br />Payment Date L36
<br />Payment Type
<br />Invoice #
<br />Check # `p �0
<br />Received By:
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<br />EHD 48-02-025 ( )
<br />REVISED 11/17/2003
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