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SAN JOAQUTA;—COUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> { SERVICE REQUEST <br /> Type of Business or Property FACILITY 113# SERVICE REQUEST# <br /> D <br /> J E N C1 I pi I NE(I-- 5 a <br /> OWNER/OPERATOR rn� ^n5l <br /> c CHECK If BILLING ADDRESSED <br /> FACILITY NAME STD h3 U+'�1 J 1�►Ey P�2�S <br /> SITE ADDRESS `u 4 a-DIli , p _?l N 1✓ ([7, LO b k q,; 4o <br /> Street Number Direction Street Name city Zip Cade <br /> HOME or MAILING:ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 0 ?&_0 t0003_;�_ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> C L6 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> -,,C D 14V_ &F-0 �nN Yv Ir1141M►PrL, yob X01-031-5- <br /> HOME or MAILING ADDRESS FAx# <br /> 40'I-- Vi- O A V_ S T. (Za`t) 3(�cI -0 3 T S <br /> CITY LPn , STATE G ZIP 9';Z40 <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 or <br /> activity will be billed to me or my business as identified an this form. <br /> I also certify that I have prepared this appli at on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 01J�p(�J _ _ <br /> If APPLICA,VT 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 environrnental/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. { <br /> i <br /> TYPE OF SERVICE,REQUESTED: REJtF—W 5;0\ 0 ll'T R31 i---1—1y I IV 1TPAT C LAfV>{tJ&- ST-V1] <br /> COMMENTS: �� D <br /> ?l� S R l tw -v~tt� �-t�i�c�tt D s S%ry tr s • Pv(z r /z sr v I'c w REG 6 OS <br /> I r[LrE E OF Tsk G° <br /> 01 <br /> ACCEPTED BY' EMPLOYEE : ATE: // <br /> ASSIGNED TO: EMPLOYEE#: DATE: w <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: /�-� Amount Paid SSS. Payment Date -7 f /b 2) <br /> Payment Type Invoice# Check# 357 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2043 <br />