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SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />—FA `Tc <br />ID # <br />A <br />SERVICE REQUEST # <br />©I� <br />0003 <br />� (o <br />S�oG(E,oT26 <br />OWNER / OPERATOR / ^ /Vt C�> <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME ArcN C 6A--5 <br />SITE ADDRESS X <br />&,... <br />/n^� /,Street <br />C � /�C/r'��l <br />/ <br />Nu ber <br />Street NaCm_e- <br />DATE: <br />1 <br />Cit (T <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />DATE: <br />Date Service Completed (if al6Ady <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 ExT• <br />6 It)Pkf S�? 3+ <br />APN # <br />LAND USE APPLICATION # <br />P — 62 I ExT. <br />) <br />BOS DISTRICT <br />L OCATION CODE <br />CONTRACTO / SERVICE REQUESTOR <br />REQUESTOR� ��� CHECK If BILLING ADDRESS <br />` -/- C. / f <br />BUSINESS NAME WE /[� ExT. <br />F !i T w 4jij <br />HOME or MAILING ADDWS /} i- <br />1 G /� Com✓ -)L—)9 7A� <br />CITY `7 E / STATE zip tcl <br />P <br />BILLING ACKNOWLEDGEMENT: 1, 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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: / <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ElIf APPLICA 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 <br />��/- <br />�REEQJU�ESpTED: �/1 <br />COMMENTS: RC f C �/"�� / �� � <br />P/� / M /� <br />f I'� 1„ 1 (�(�� <br />L(&� l,�rTfP <br />D609L� SLC—`- <br />IlL •. <br />ACCEPTED <br />- <br />EMPLOYEE #: <br />DATE: <br />1 <br />ASSIGNED TO: <br />EMPLOYEE #: / 2 <br />DATE: <br />Date Service Completed (if al6Ady <br />completed): <br />SERVICE CODE: <br />PIE: 2 <br />Fee Amount: <br />Amount Paid <br />3 b <br />Payment Date l I b <br />Payment Type <br />Invoice # <br />Check # A 2 b q 5 -2__ <br />1 Received By: _ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />41 <br />