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SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID '# <br />SERVICE REQUEST # <br />BUSINESS NAME <br />-rftono <br />1910 0 C" <br />OWNER / OPERATOR <br />a' , / l ;lw <br />CHECK If BILLING ADDRESS <br />FAClLLiTTY NAME M 'V ws-1 , ,n <br />N <br />FAX# <br />SITE ADDRESS �j�) S <br />CITY 73 64? 191-Pyk <br />^ �N <br />Fr <br />ZIP <br />M n . ,Aia✓.A <br />ci <br />A /33 6 <br />'7 >Zio <br />Street Number <br />Direction <br />Date Service Completed (if already completed): <br />Street Name <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Amount Paid�� <br />° M•- <br />Payment'Date <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />109 9 9-3 Z628' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 12 <br />PAYMENT <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />1 <br />EXT. <br />A&0 <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY 73 64? 191-Pyk <br />STATE fA <br />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 JOAQULN <br />COUNTY Ordinance Codes, Standards, STATE and F ERAL. laws. <br />APPLICANT'S SIGNATURE: DATE: 7 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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 to the SAN JOAQULN 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: <br />PAYMENT <br />COMMENTS: <br />JUL 2 3 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE #:} { <br />DATE: <br />ASSIGNED TO: fr,, A <br />4,4 <br />EMPLOYEE#: 1- <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount:; <br />Amount Paid�� <br />° M•- <br />Payment'Date <br />Payment Type - <br />Invoice # <br />F P <br />Check #` a15 -f -2 <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />