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SAN JOAQUIN*UNTY ENVIRONMENTAL HEALTH *RTMENT <br />SERVICE REQUEST. <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />BUSINESS NAM <br />CHECK if BILLING ADDRESS <br />OWNER / OPERATOR \ �J <br />�co C P I D v0 ` J <br />FACILITY NAME <br />J (�� <br />SITE ADDRESS <br />"t <br />CITY <br />STATE zip <br />i <br />J v L <br />T' c, c,1 <br />qg3 <br />Street Number <br />Direction <br />Stre <br />DATE: <br />/-7/C7 <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site <br />Address) <br />P/ E: 2'�> C, <br />Fee Amount: tas" —' <br />Sheet Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 ExT. <br />Check # 2q <br />APN # LAND USE APPLICATION # <br />fq- <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION COD <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/I <br />U7 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />^ 1 <br />HOAlQU1N <br />PHONE# EXT. <br />zak 3eS- b <br />HOME or MAILING ADDRESS <br />7-5- r0- <br />FAX# <br />(2 -bet) 36S-- lS`(3 <br />CITY <br />STATE zip <br />i <br />Z <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or businessowner, operator or authorized agent of same, <br />acknowledge that all site and/or project spe�ific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed tome or my busine s 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, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER❑ <br />If APPLICANT is not the <br />DATE: 1—)1— OZ <br />/MANAGER ❑ OTHER AUTHORIZED AGENT G trC o <br />4RTY, proof of authorization to sign is required Title <br />AU I HVIULA r1V1y 10 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. YME(�j <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />^ 1 <br />HOAlQU1N <br />GOUNTY <br />SAN NTAL <br />EN�IRONME <br />1 IEALTH DEPARTMENT <br />ACCEPTED BY: L t t, tis <br />EMPLOYEE #: C 2_1DATE: <br />1 / <br />ASSIGNED TO: N <br />EMPLOYEE M 7 y <br />DATE: <br />/-7/C7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: 9 <br />P/ E: 2'�> C, <br />Fee Amount: tas" —' <br />Amount Paid <br />Payment Date( �-1 0 -7 <br />Payment Type <br />Invoice # <br />� <br />Check # 2q <br />Received By:lfL <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />