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1 SAN JOAQk. COUNTY ENVIRONMENTAL HEAL1 )EPARTMENT <br />SERVICE REQUEST <br />Type <br />I/Ura <br />of Business or Propeity <br />tte' Na . on ' ed veil Yle.). <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR , , __. 9 <br />,0 CHECK if BILLING ADDRESS if <br />P 0_0 MI no <br />FACILI <br />ES (pi* rio <br />SITE ADDRESS <br />v Street Number i t.\-- <br />Direction <br />Itri4. <br />Street Name , a ofie:sro <br />City Zip Code <br />HOME Or MAILING ADDRESS <br />01 q 0 .010(6 <br />(If Different from Site Address) <br />L rlith(b 4-61 Street Number Street Name <br />STATE <br />q&aiTY - WI <br /> <br />15-'39 b <br />PHONE#1 EXT. PHONE <br />(Ahl ) 1 5--'-'3P61M <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HomE or MAILING ADDRESS FAx # <br />( ) <br />CITY STATE ZIP <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 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, Stand rds, STATE and FEDE laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER • OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTI; proof of authorization to sign is required <br />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. <br />TYPE OF SERVICE REQUESTED: --eZ4:7 tie:if( C(1. <br />COMMENTS: e5,- „,.....____ <br /> <br />7 U --(--- 4 A 2C) Z- Goiti,4 0 /IOW° /i- <br />ECEA <br />e. <br />R <br />OCI — 5 <br /> ZAT <br />' w"° Rooter' err <br />ACCEPTED BY: <br />ftlit <br />EMPLOYEE #: <br />vizrorl enTY <br />DATE: (0/5-/I2 <br /> <br />ASSIGNED TO: <br />id4/14 <br />EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: D6/ PIE: ib,0 <br />Fee Amount: 12--C. c ‘. Amount Paid Payment Date i <br />Payment Type *(f7 Invoice # Check # Received By: <br />DATE: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003