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SAN JOA COUNTY ENVIRONMENTAL HEA' ,fl PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />v c>l l L IL <br />akku c1,ea s-Ict !e w G r <br />PHONE# <br />EM' <br />S'i2CC,(;-7gz-7 <br />OWNER / OPERATOR <br />L <br />ASSIGNED TO: Q ^/?, Q <br />CHECK if BILLING ADDRESS❑ <br />ove <br />FAX # <br />DATE: <br />vc� 0 k fii'ec� <br />FACILITY NAME -li 22 q <br />�Q h <br />CITY ' U I Iq P- C <br />O > <br />1 <br />C7 <br />Payment Date (p <br />SITEADDRESS <br />= invoice # <br />II'R. <br />Check # <br />�((��] <br />Received By: <br />SStreet Number <br />Direction <br />�� <br />eet a e <br />T�nci <br />i o e <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />' <br />Street Number <br />Street Na e <br />CIN /� <br />STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />() <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS iIAMEFO(CA L <br />v c>l l L IL <br />akku c1,ea s-Ict !e w G r <br />PHONE# <br />EM' <br />4 n !. <br />DATE: <br />ASSIGNED TO: Q ^/?, Q <br />HOME or MAILING ADDRESS <br />EMPLOYEE M <br />FAX # <br />DATE: <br />vc� 0 k fii'ec� <br />( ) <br />CITY ' U I Iq P- C <br />STATE C,I <br />ZIP 3� 71, <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 ENVixom ENTAL 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. R <br />APPLICANT'S SIGNATURE: ` DATE: <br />tt <br />PROPERTY / BUSINESS OWNER❑ OPERA OR / MANAGER 13OTHER AUTHORIZED AGENTIJ (1, ��u�'. <br />IfAPPLICANT is not the,BILLINGPARTY 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: UST <br />COMMENTS* <br />�� ti� G-\ j ►�s l i all We.�j�r <br />UYl�(,c�cS l l� �2 C c��!�ti V See <br />v c>l l L IL <br />akku c1,ea s-Ict !e w G r <br />ACCEPTED BY: V 0 <br />\+AA <br />EMPLOYEE M 3 l <br />J <br />DATE: <br />ASSIGNED TO: Q ^/?, Q <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: t <br />Amount Paid <br />37Jc <br />Payment Date (p <br />Payment Type �; S �__ <br />= invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 PAYM E^ � ' ' v �� ✓ SR FORM (Golden Rod) <br />REVISED 11/17/2003 RECEIVED <br />JUN 2 1 20':3 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />