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SAN JOAQUIN LINTY ENVIRONMENTAL HEALTH DORTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CZ � S� EI�O�i <br />t , <br />FACILITY ID # <br />`) rSE/RMCE%R(EEQUEST # <br />✓1�l.�li Yi / <br />OWNER/ OPERATOR <br />15 1-e �{���-fU✓� <br />CHECK I(BILLING ADDRESS � <br />FACILITY NAME <br />HOME or MAIUN A¢DRESS <br />�a UQ�tVLVI /4ve <br />SITE ADDRESS <br />Street Number <br />Direction <br />Street Name <br />CITY '�iA 40 i Q- <br />CI <br />'t ZipCode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Date Service Completed (if already completed): <br />Street Name <br />CITY <br />PIE: 'Z M <br />STATE ZIP <br />PHONE#1 EV. <br />LTL—) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />I invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />M(ta 11�ceL{-({-(L AA. <br />t , <br />CHECK if BILLING ADDRESS ICI <br />BUSINESS NAME 3C.t/lf l Com. J+U:ftLY4 J %t-uas -Vvc • <br />td -+ k 1{6i.7 <br />REC <br />lv, AI 2 <br />fpt <br />PH O T <br />(�� <br />243 ' 4 O'3 Y Exr. <br />HOME or MAIUN A¢DRESS <br />�a UQ�tVLVI /4ve <br />DATE: <br />FAX# <br />(,46?) <br />x -H-604 <br />CITY '�iA 40 i Q- <br />STATE eg <br />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 EN iRoNMENTAL 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. <br />APPLICANT'S SIGNATURE: �/y{(rte ,jJ. Q.Lt3a DATE: <br />VIO HRIZEDPROPERTY/BUSINESS OWNEROPERATOR AGENTE�`Ui��Jts'A$o1GOG��r// <br />IfAPP,UCANT is not the BiLLi7VGPAR proof of authorization to sign is required "Ttrte <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 environinental/site assessment <br />infomtation 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: ` <br />t , <br />COMMENTS: SSS (Vi,'�Q,I C —40 IVIS-kL..a QiA E+k U{'. eGJUaWVLCC4 C)1 <br />`i�Q S 3� VlAbwtior 4 f�tR Nt SCS C <br />td -+ k 1{6i.7 <br />REC <br />lv, AI 2 <br />ACCEPTED BY: <br />EMPLOYEE#: O <br />DATE: <br />VIRCH <br />ASSIGNED TO: <br />EMPLOYEE#: 3J0 O <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: �'� <br />PIE: 'Z M <br />Fee Amount: AQ-79-OQ <br />I Amount. Paid <br />LTL—) <br />I Payment Date <br />y O t� <br />Payment Type L,,� <br />I invoice # <br />Check # Inri <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />ENT <br />IVED <br />2 2006 <br />1114 COUP -1'Y <br />NMENTAL <br />EPARTMENT <br />