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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTF =PARTM ENT <br />SERVICE REQUEST <br />Type of &siness or Property <br />CHECK If BILLING ADDRESS 19 <br />FACILrrY ID # <br />i I� 5 1v c� 1v <br />SERVICE REQUEST # <br />S�f�_c �) q �0 sy � <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FAauTY NAME <br />LAv� <br />STATE C' eA ZIP C� —37 c <br />9TEAoDFEs <br />Street Number <br />Direction <br />tA pja O01 C <br />Svre Name <br />Date Service Completed (if already completed): <br />tai <br />Cit <br />Code <br />How ortNNUNGAODFczsS (If Different from Site Address) <br />Street Number <br />PIE Z3 CO <br />Street Name <br />CITY <br />Payment Date <br />STATE ZIP <br />PHON #1 Ex-r.APN <br />(2c. i) &( I - \S-5- 1 <br />Invoice # <br /># <br />LAND USE APPLICATION # <br />NOW IQ EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR � ^ �i -0 c) <br />1�', r <br />CHECK If BILLING ADDRESS 19 <br />BUSINESS NAMEPFUE# <br />A L_ L1__F Co <br />i I� 5 1v c� 1v <br />EXT. <br />-zC ! s -z-- J 3 z C <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY ^ (` ,` <br />STATE C' eA ZIP C� —37 c <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on thisform. <br />I also certify that I hate prepared this application and that thework to be performed will be done in accordancewith all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL IaVS. <br />APPLICANT�SSIGNATURE: :�� DATE: <br />PROPERTY/BUST NESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT 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/ate assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Sam- a time it is <br />provided to me or my representative. [A, -,,T- i 2 7.72-c',F / <br />TYPE cF SeancE FEQUEsTEo: F C/2- rvl T <br />1 l� r1 CL C 1- V 1 S CDJ�s 6, <br />Carrs: (� C U <br />i I� 5 1v c� 1v <br />�% I -P 1 tii C� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: 5,��lj <br />GATE: <br />Date Service Completed (if already completed): <br />SENIcFC CDE: <br />PIE Z3 CO <br />Fee Amount: c/ cv <br />Amount Paida �� vfc) <br />Payment Date <br />O <br />Payment Type �/ rs <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />