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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 4 SERVICE REQUEST'# <br /> OWNER/OPERATOR <br /> CHECK.if Sit LIN AADDRFS$0 <br /> FAC:TY NAdiE <br /> i <br /> SrT DDRES5. i <br /> ,✓{/ SYaabNurnbcr DfrFittTr�n Str*At Name '' # 1 7_tn Coln I <br /> HwAE:or MAJUNG ADDRESS (If Different#rorty Site Address) .!� �� {✓ ': -7 f7 J <br /> CITY <br /> f Servet flumbru Str¢ai:name <br /> STATE ,r/ Zip c � <br /> PHDNE#1 AF N# ' LAND USE Ar ixitCAT3C N# <br /> PHQNEm2EXT. SQ5'DtSTRCT IDCTiDNCOAE <br /> l ? <br /> CONTRACTOR SERVICE REQUESTOR <br /> i REQtlESTOR <br /> f7 ✓.�..} ,:,�'S C C,.t %' CHECK if SILUNG.AbDRFsso � <br /> {, BUSINEsSNAme PPHONE# <br /> HOME or MAILING ADDRESS FAX# <br /> 7/moi ✓u'c t I <br /> Crrr STATE x'74- zipC�Gr <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site andior project specific ENVfRoNmENiTAL HEALTH DE piA,RTAAENT hourly charges associated with this project or <br /> activity will be billed f me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be pe0ormed will be.done in accordance winh all.SAN JOAQuiN <br /> COUNTY Ordinance Cade..%Standards,S-rATe and'FsoaRAL laws. <br /> APPLICANT'S SIGNATURE: � ,r e-�" —1 DATE: <br /> PROPERTY I BUSINESS OWNER D OPERATOR I MANAGER Ci OTHER AUTHORIZED AGENT D <br /> IfRppucAfrr is not the Bit i,4jvc Rte,proof of authorization to sign is required T xrt� <br /> AUTHORtZATiOtd TO RELEASE INFORMATION: When applicable, i, the owner or operator of the property located at die abo,,ie <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site aSsessMent ijl�W-4=ri <br /> to the SAN JoAouiN Clouigy ENVIRONMENTA:.HEA;,TY,DEPARTMENT aS soon as it is available and at the Sarne time it is prov,deo j�IY x§ <br /> Pµ <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �✓ � I �i.:�✓� � �jl� � <>� `"w <br /> k f <br /> t !` j�,Jul � '3 {.d {•"`✓ wP,r i { g B <br /> l <br /> AccEpm ByEMPLOYEE#: <br /> ASSIGNED T0: Bipj-oYEE#: MATE: j <br /> Date Service Completed (if already completed): SERVICE CODE-, /, { P,E: L-) <br /> Fee Amount: Mount PaBate —7/� <br /> r '� r t Pa rnent / 1 <br /> '�' : , �,�'' y <br /> Payment Type rLL h invoice# Check# Received <br /> I <br /> EHG 4E-02-025 SR FCJkM(Golden Rod) <br /> 07!17,'08 <br />