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SAN JOAQUINWQUNTY ENVIRONMENTAL HEALTitEPARTMENT <br />SERVICE REQUEST <br />Type of Businu'ss or Property <br />BUSINESS NAME n � I <br />u �-d M1 Cs 1—�- <br />/ FACILITY ID # <br />SERVICE REQUEST # <br />A--> STS �-rl v� <br />CITY /i _ STATE ZIP C S 1 ' <br />Y <br />2� <br />-�� �' & C) YV <br />OWNER / OPERATOR <br />/ <br />i CHECK If BILLING ADDRESS <br />EMPLOYEE #: -7 (y <br />DATE:/meqLf <br />Date Service Completed (if already completed): <br />FACILITY NAME 'A <br />P I E: Z/'� 0 <br />Fee Amount: �� � <br />SITE ADDRESS �� L.t L4 <br />I <br />Payment Type <br />m U �S i/�.ALC <br />�a <br />- <br />�^ i , A ")A <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />,VU C, .oK <br />% I -'t Street Number <br />Street Name <br />CITY cu—"CLI <br />STATE <br />l <br />Zip <br />`Z <br />PHONE #'I <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />904)-� <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />(0() <br />11 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ^mak v) 6 CHECK if BILLING ADDRESS❑ <br />BUSINESS NAME n � I <br />u �-d M1 Cs 1—�- <br />PHONE#) Ems' <br />HOME or MAILING ADDRESS <br />w -774-7( <br />FAX # <br />) <br />CITY /i _ STATE ZIP C S 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, Standards, STATE nd F law ,%--) <br />APPLICANT'S SIGNATURE: e DATE: :1.492/f <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 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: <br />�'Qy <br />COMMENTS: <br />~•0qo�, v2004 <br />ACCEPTED BY: <br />EMPLOYEE #: S a 0 <br />DATE: O <br />ASSIGNED TO: <br />EMPLOYEE #: -7 (y <br />DATE:/meqLf <br />Date Service Completed (if already completed): <br />SERVICE CODE:J <br />P I E: Z/'� 0 <br />Fee Amount: �� � <br />Amount Paid` <br />Payment Date a' <br />Payment Type <br />Invoice # <br />Check # = Vlrr <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />