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SAN JOAQU V OUNTY ENVIRONMENTAL HEALTWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />J.f ` <br />FACILITY ID # <br />BUSINESS NAMEY <br />L4G <br />SERVICE REQUEST # <br />PHON,EE# EXT. <br />VI &/-6 <br />FAX# <br />Gr&o <br />FA0003f-v3 <br />OWNER / OPERATE <br />' i <br />ZIP <br />STATE It 1% <br />CHECK if BILLING ADDRESS <br />FACILITY NAME aLj <br />it- n <br />( ue-c 12--,4 <br />SITE ADDRESS <br />EMPLOYEE M 2— <br />DATE: 5-'� / o f <br />L <br />Ke,+-H <br />L � <br />!� S� <br />Street Nu ber <br />Direction <br />Date Service Completed (if already completed): <br />Name <br />cityZi <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />25?� <br />Amount Paid 14> Ji-) <br />Payment Date 57q0b%' <br />Street Number <br />1i'' <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICT / <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />J.f ` <br />CHECK If BILLING ADDRESS ' <br />BUSINESS NAMEY <br />L4G <br />lY <br />PHON,EE# EXT. <br />VI &/-6 <br />FAX# <br />HOME or MAILING ADDRESS <br />616-3 s wt' <br />[61-Ty—S1 O I/ <br />WJVkOT4 <br />fo Drop TME{+R <br />ZIP <br />STATE It 1% <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 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, Standard , TATE and FEDERAL laws. <br />APPLICANT'S SIGNAT DATE: 15--17-000 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT St'di Gt a Crr� 11�Lt.IV'"/ <br />If APPLICANT 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 environmental/site assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an the same time it is <br />provided to me or my representative. ?AYM p <br />TYPE OF SERVICE REQUESTED:(�: S 1 <br />yC r 7 <br />COMMENTS:F- <br />WJVkOT4 <br />fo Drop TME{+R <br />NPAE <br />ACCEPTED BY: <br />( ue-c 12--,4 <br />EMPLOYEE M 2— <br />DATE: 5-'� / o f <br />ASSIGNED TO: <br />L� t r <br />EMPLOYEE #: 1 ! ZZ <br />DATE: �[[�Q <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I : 2-3 O f - <br />Fee Amount: <br />25?� <br />Amount Paid 14> Ji-) <br />Payment Date 57q0b%' <br />Payment Type <br />1i'' <br />Invoice # <br />Check # � <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />