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10 <br />SAN JOAQUI&UNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME CAI A L N <� C <br />FACILITY ID # <br />PHONE # EXT• <br />17t6 3•x-3 - /tsz <br />SERVICE REQUEST # <br />CN2�> & o C <br />vI- L <br />CITY <br />STATE C A ZIP 1 <br />�EB <br />5 �Zvd - �-5 9 s - <br />OWNER / OPERATOR <br />❑ <br />A ( C ` C Q O ( L <br />C O �/ <br />L l <br />CHECK if BILLING ADDRESS <br />FACILITY NAME MC -11C4 <br />CIL At N Z <br />DEPPRS <br />H�IN <br />S 2 <br />SITE ADDRESS <br />EMPLOYEE #: C, j <br />A -T E2 L 0 O RD . <br />ASSIGNED TO: <br />S7 ro C K T - o K( <br />EMPLOYEE #: 9Y Cl- <br />3300 Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Paid <br />\ S - <br />Payment Date <br />Z3 O <br />b <br />Street Number <br />L, <br />Street Name <br />CITY A <br />STATE C ^ ZIP ^�5 10z— <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE K <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / r` I C W ( t ,4 C <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME CAI A L N <� C <br />COMMENTS: <br />PHONE # EXT• <br />17t6 3•x-3 - /tsz <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY <br />STATE C A ZIP 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 <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 andat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA and FE RAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER [3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C B*iI —re <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. (QST ✓�'07y' 61 F tT „vnAENT <br />TYPE OF SERVICE REQUESTED: P Arr( T2 E= V1 FiW <br />:L7,4 S P <br />COMMENTS: <br />�EB <br />SAN SOA ONMEN Wi N., <br />DEPPRS <br />H�IN <br />ACCEPTED BY: <br />�u 1✓t i- � <br />EMPLOYEE #: C, j <br />DATE: 2 11 /C c, <br />ASSIGNED TO: <br />Vi✓ ,�j L� <br />EMPLOYEE #: 9Y Cl- <br />DATE: Z Y/6 c^ <br />Date Service Completed (if already completed): <br />SERVICE CODE: 4 <br />PIE: <br />Fee Amount:Amount <br />-its; ,t <br />Paid <br />\ S - <br />Payment Date <br />b <br />Payment Type <br />L, <br />Invoice # <br />Check # `4 Ll <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />