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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDM SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FAcu.rtY NAME PIP7 E til ee/77AA/V '+ <br /> SITE ADDRESS p.,/ /y I�SSDAG-E I-Ari//Zo!' 9s 33a <br /> p Street Name Cit Zi C de <br /> f7 d 9oa Street Number Direction <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street ame <br /> STATE ZIP <br /> � CITY <br /> LAND USE APPLIC ION# <br /> Ext. APN# <br /> PHONE#1 <br /> O 3 O-4219 � L�OC�ATION"'C_OD.E <br /> #2 EXT. BOS DISTRICT � <br /> ' <br /> l CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK If BILLING ADDRESS <br /> E.T. <br /> PHONE# /o4 _ O <br /> BusimEss NAME L A1 <br /> FAx# <br /> HOME or MAILING ADDRESS ( ) <br /> STATE ZIP S SS <br /> CITY <br /> BILLING ACKNOWLEDGENtENT: I, the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and/or project specific ENY'IRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this forth <br /> I also certify that I have prepared this a;Ao'f <br /> kation and that the work to be perfomud will be done in accordance with all SAN JOAQUIN <br /> Coum Ordinance Codes,StandardsL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> �l �� 7 — aW— <br /> PROPERTY I BUSINESS OWNER❑ R ❑ OTHER AUTHORIZED AGENTM Title <br /> If APPLICANT is 1101 die.BILLWr'R.aRTY proof <br /> authorization to sign is required <br /> ALTtTIORITATION TO RELEASE INFORMATION: When applicable, I, tite owner or operator of the property located at die <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 Cowry ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to Tire or my representative. <br /> TYPE OF SERVICE REQUESTED: ,(7T <br /> COMMENTS: 1"AYM��IU I ) rr <br /> r , � y I <br /> DATE: <br /> ACCEPTED BY: L jL 1 V t y:� VepaTM- DE EMPLOYEE 9: 03 a <br /> EMPLOYEE#: S 3ti DATE: 7 GS <br /> ASSIGNED TO: )ti-( k d ,Til 7Q <br /> Date Service Completed (if already completed): <br /> SERVICECODE: 5"2-S 91.S P1 <br /> Fee Amount:' c-J �. �� 91A10 <br /> Amount Paid C, p y Payment Date <br /> Invoice# Check# 'J. c:'- Received By: <br /> Payment Type � •� F,0 <br /> SR FORM(Golden Rea l <br /> EHD 4M2-025 <br /> REVISED 11/17/2003 <br />