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SAN JOAQU :OUNTY ENVIRONMENTAL HEALTH 'PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />L <br />�j CY <br />SERVICE REQUEST # <br />S Cab g 3 v h C) <br />OWNER / OPERATOR <br />/ � L- (- � � � <br />V <br />CHECK If BILLING ADDRESS <br />FACILITY NAME S n -^ <br />�•' <br />FAx # <br />(2-0`h--�-33 <br />SITEADDRE� <br />Gt Street Number <br />Direebon <br />�rn .i{ �7 / D p2 <br />v 14 "Street Nam <br />SILKS <br />Ci <br />cjS �./ 7 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SAN JOAQUIN COUNTY <br />Sheet Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( 1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r� <br />I /� •� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />L <br />�j CY <br />COMMENTS: <br />PHONE# EXT. <br />(207) 5-3 Z - 73 -L o <br />HOME or MAILING ADDRESS <br />- i> - C ( <br />FAx # <br />(2-0`h--�-33 <br />CITY Nr -Q <br />STATE CAZIP <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 ENvtRONMENTAL 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 />_.-- <br />APPLICANT'S SIGNATURE: / /�/hti DATE: 7 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MvNAGER ❑ OTHER AUTHORIZED AGENT rFr,STEZL <br />IrAPPLIC.4A'T is not the BILLIA'G 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/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. uS T' F- t 1 <br />TYPE OF SERVICE REQUESTED: /RG7P LA C C- <br />CLQ O N D 1 t_Z_ 74 AJ <br />'-tVP, I if <br />COMMENTS: <br />PAYMEN <br />RECEIVED <br />JUL 15 2005 <br />SAN JOAQUIN COUNTY <br />ACCEPTED BY:EMPLOYEE <br />�A <br />#: I <br />f�3 i <br />-Vn <br />'C <br />ASSIGNED TO: E- <br />EMPLOYEE #: 35,f -b- <br />DATE: <br />( <br />Date Service Completed (if already completed): <br />SERVICE CODE:P <br />I E: <br />u <br />Fee Amount: -7 <br />Amount Paid <br />Payment Date '1 <br />Sri <br />Payment Type V11" <br />Invoice # <br />Check # g ((` <br />Received By: ' <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />I- <br />