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I <br />+` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />I <br />CHECK if BIWNG AD <br />SERVICE REQUEST # <br />S7 •4' <br />vrn <br />BUSINESNAME r '' <br />PHONE # <br />�i "3 ? <br />OwNE /OPERATOR t/ <br />19 /�G�%GGt� <br />CHEprifBIWNGADDRESS❑ <br />FACILITY NAME6 (j57 <br />(I[S C Y <br />Date Service Completed (if already completed): <br />I <br />HOME or MAILJNG ADDRESS <br />� 3 ) <br />/ - /J/ <br />" Street Number <br />Dkectbn <br />Street Name <br />1 S <br />city <br />ZIPCede <br />HQM G ADDRESS (If Different from Site Address) <br />Check It q b Z <br />Street Number <br />-STATE <br />C y <br />Zip <br />4� <br />Exr. <br />PHONE #1 <br />ApN # <br />LAND USE APPLICATION # <br />PHONE #2 Ekr• <br />BOS DISTRICT LOCATION CODE <br />CnNTR ACTOR / RF.RVICE REOUESTOR <br />REQUESTOR v v <br />CHECK if BIWNG AD <br />y <br />ACCEPTED BY: OL � 0EEMPLOYEE <br />l � <br />BUSINESNAME r '' <br />PHONE # <br />�i "3 ? <br />(/ /� �/ En. <br />a7 �" / O <br />�lv <br />EMPLOYEE#: P3-73 <br />(I[S C Y <br />Date Service Completed (if already completed): <br />SEIMCE CODS (q g <br />HOME or MAILJNG ADDRESS <br />� 3 ) <br />/ - /J/ <br />CRY . <br />STATE <br />LP <br />1 S <br />Payment Type <br />L <br />BILLING ACICGOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEATH 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, StandardsTATE and FEDERAL laws. <br />HATE: ! ) 3 <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER43 OTHER AUTHORIZED AGENT <br />IfAPPL1C4NT is not theBILUNGPARTY. proof of authorization to sign is required Title 1 n _ A, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property loom �.� <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site � iA t <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEATH DEPARTMENT as soon as it is available and at the same time it is <br />� �oO� <br />-A-A --m roCPfltAtlVP �� Iml <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS:�i I <br />)—byl cl l � 01V ire <br />777 ENTH DE <br />H�- <br />q--' �;L&xe-' u/ <br />ACCEPTED BY: OL � 0EEMPLOYEE <br />l � <br />#: O 3L1 <br />DATf: / / ,S G <br />ASSIGNEDTO: V �0 ti <br />EMPLOYEE#: P3-73 <br />(I[S C Y <br />Date Service Completed (if already completed): <br />SEIMCE CODS (q g <br />PIE 23.0 e <br />Fee Amount: 4L7 9 , pp <br />Amount Paid a 1 l(, <br />Payment Date <br />It <br />d Lf <br />Payment Type <br />Invoice # <br />Check It q b Z <br />Received By 21L/ <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />'' r <br />1 GQUN t a <br />iENTA"- <br />ARTMEPI? <br />SR FORM (Golden RoZ pv <br />