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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�t,� , <br />PHONE # <br />ExT. <br />off- /5737 <br />' 14 <br />L U ,�.� <br />FALX]# <br />/ <br />( 14) <br />! �} <br />N-11% <br />CITY <br />OWNER/ OPERATOR 1-.�pU P (f%J (2� �(R <br />p H I L L O t CHECK <br />Date Service Completed (if already completed): <br />if BILLING ADDRESS <br />FACILITY NAME C µ C V PO AJ <br />ADDRESS <br />r <br />i x <br />011 TF -Cd <br />� <br />-12 Street Number <br />invoice # <br />Street <br />e[ Name <br />By:16 <br />deSITE <br />HOME or MAILING ADDRESS of Different from Site Address) <br />LEA <br />ASA I <br />S Number -Street Name <br />CITY Z RAl C—Y <br />STATE !a A ZIP (] s � O q <br />l <br />PHONE #'1 Exr- APN # <br />t ISE APPLICATION # <br />PHONE #2 q. Ext. <br />) <br />•OS DISTRJCT LOCATION CODE <br />7 <br />CONTRACTOR/ SEKvi%-,L _,EOUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS LSI <br />BUSINESS NAyE <br />fic) <br />�t,� , <br />PHONE # <br />ExT. <br />off- /5737 <br />HOME Or MAILING ADDRESS <br />�/ <br />7`- - <br />EMPLOYEE#: �7V <br />FALX]# <br />/ <br />( 14) <br />! �} <br />N-11% <br />CITY <br />STATE i►w <br />zip �rg� <br />i <br />BILLING ACKNOWLEDGEMENT: I, the undersigned prope or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONIviENT. HEALTFT DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on 4s form_ <br />I also certify that I have prepared this application and that ther`work to be performed will be done in accordance with all SAN JOAQUIN <br />CommY Ordinance Codes, ,Standards, STATE and FEDERAL aws. <br />n <br />APPLICANT'S SIGNATURE: DATE: <br />PROYER"J1 / BL'S4YESS OWNER❑ O BATOR / NLA_N GFR OTHER AUTHORIZED AGENT ❑ M %kwS OtC-ACIZ, <br />If APPLIGLVT isnot t e BJLLLAYG PARTY proof of autliorkafion to sig t is required Title' <br />AUTHORIZATION TO RELEASE INFORM ION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the rel-e��-a///s`e of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENV1tZONIVIEVTAL 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: <br />COMMENTS: A Od <br />VI <br />C C <br />NAY f 1 <br />i`! All/, UlIV C <br />ACCEPTED BY: a:✓ <br />EMPLOYEE#: �7V <br />DATE: II _ FpgRT <br />ASSIGNED TO: �'� <br />EMPLOYEE #:� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( <br />P1 E: A.311) <br />v <br />Fee Amount: <br />Amount Paid <br />4. 1 1 f � o <br />Payment Date <br />5 8 1/ 1 7 <br />Payment Type ✓ <br />invoice # <br />Check # 21 -7 4(Received <br />By:16 <br />EHD 48-02-025 <br />REVISED 1111712003 <br />SR FORM (Golden Rod) <br />� <br />Nr <br />p® <br />