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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# 4 <br />64' :' S (- 477 O t, -)v) <br />ExT. <br />-_ �. <br />l <br />100 <br />OWNER / OPERATOR <br />r _ .%fit r7o c- t f(�j <br />/ <br />li��l <br />(`� <br />CITY STATE <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZO2 s <br />DATE: y 01 <br />SITE ADDRESS Z <br />\A.) <br />>, j '�, V, (44 IC/- <br />`t <br />PIE: . <br />cJ �� / To <br />G <br />Amount Paid <br />Street Number <br />Direction <br />Payment Type �,-' <br />Street Name <br />Ci <br />Zi Code <br />HOME MAILING ADDRESS (if Different from Site Address) <br />�6ja <br />—��L�(r�Lh�vl�� j�" I -9/3,D <br />� � <br />�or <br />1 e r l s l,�tci L � <br />Street Number <br />Street Name <br />CITY �- � <br />STATE _ ZIP '2� <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(1:7(0 Z -/,7-0Z0( <br />PHONE #Z ExT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR fr �A <br />(l <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME / <br />eSs�. �L . a vie�i�cC v►4��r( <br />PHONE# <br />ExT. <br />-_ �. <br />HOME or MAILING ADDRESS <br />.2-51S E (9ZGCZC7t„ J , , M- <br />FAX# <br />(11,L) <br />372--1376 <br />CITY STATE <br />ZIPC 5 - <br />BILLING ACKNOWLEDGEMENT: 1, 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, StandardsMSan�d FEDEERAL laws.�j�/ APPLICANT'S SIGNATURE: lam- DATE: ` 7 q / <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT t2 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />ll Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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.PAYN1��'`�T <br />" <br />TYPE OF SERVICE REQUESTED: CSF /C e- <br />COMMENTS: <br />JUL 1 <br />SAN 3, �NMENT NN <br />ENVIF3pEP�T1�AENT <br />HEAI-TM <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: / <br />`Completed <br />EMPLOYEE #: <br />DATE: y 01 <br />Date Service (if already completed): <br />SERVICE CODE: <br />PIE: . <br />Fee Amount: 1-0 <br />Amount Paid <br />3 S, O <br />Payment Date 'Z t -t v <br />Payment Type �,-' <br />Invoice # <br />Check # ItF -7 b r S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />