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SAN .JOAQL. r COUNTY ENVIRONMENTAL HEALTH iiEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS iVAMEe� /J <br />(� l <br />SERVICE REQUEST # <br />46-S 63 <br />HOME or MAILING ADDRESS 7 <br />FAx # <br />OWNER/ OPERATORIQ�I <br />A n / —� <br />g , V (�� <br />f <br />CHECK if BILLING ADDRESS LCJ <br />FACILITY NAME _ . <br />s <br />CITYSTATE <br />SITE ADDRESS -57.4 <br />� �\ <br />I <br />2-m rz m c /6,4) <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: Zel Aa <br />Street Number <br />ction <br />Street Name <br />Date Service Completed (if already Completed): <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P 1 E: <br />Fee Amount: - <br />Street Number <br />s <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APIN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i <br />CHECK if BILLING ADDRESS <br />BUSINESS iVAMEe� /J <br />(� l <br />COMMENTS: <br />L1rIZ��>��R-�1 Psi <br />PHONE # Q 7 �I /y EXT. <br />HOME or MAILING ADDRESS 7 <br />FAx # <br />�EBpy20�9 <br />Qu�ME� EN <br />CITYSTATE <br />�/� r 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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, PATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: V`J^ DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />/f APDL/CANT 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 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: t:- V <br />IL le Vj PP-rr) <br />, mer~ ` <br />COMMENTS: <br />L1rIZ��>��R-�1 Psi <br />�L-S ��� <br />�EBpy20�9 <br />Qu�ME� EN <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: Zel Aa <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: - <br />Amount Paid <br />s <br />Payment 6aie <br />Z <br />Payment Type <br />Invoice # <br />Check # `� 0� <br />Received By: %V11r- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />