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• 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />I� CiI <br />oV <br />L� <br />OWNER / OPERATOR _ <br />CHECK If BN.uNSi ADDREss❑ <br />ACCEPTED BY: <br />EmpLoYEE# S> <br />DATE: �t v <br />FAgLITY NAME ' c <br />,t <br />— <br />Cy <br />EMPLOYEE#: L. -(o Lf <br />DATE: -1 - <br />SITE ADDRESS <br />SITE O <br />trr eat Number Direction <br />► K R tis <br />' Ire <br />am <br />Ct <br />e <br />HOME Or MAIUNG ADDRESS (If Different from <br />Site Address) <br />Payment t Date <br />(o11 v <br />Payment Type V 15 �, <br />Invoice # <br />StreatNumber <br />Check # <br />tre tName <br />CITY <br />STATE LP <br />PHONE #1 Exr. <br />(wci cK39--5m <br />APN # <br />LAND USE APPLICATK)N # <br />PHONE #2 Ext. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE Q ESTO <br />REQUEST°R— uCACLO JV%MyaJ%CxVVl V9tL0ef!+4fH <br />CHECKffBIWNGAOO=sa <br />l ear- <br />BUSINESS NAME _ I I r Q _ E# `A ' 9 16 E. <br />HOME or MAIuNG ADDRESSI FAX# <br />q(410 YrAntee- l (ql(e (P 2�"C�`"1 <br />CITYbv-I 10 STATE CA 7JP 95-6-7-7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE d FERE <br />APPLICANT'S SIGNATURE: DATIE: <br />PROPERTY/ BusINEss OWNER❑ OPERATOR / i11ANAGER ❑ OTHER Atrn[ORIZED AGENT 0 �Qfj�f t /rbc S <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 />� - Ep <br />COMMENTS: <br />p?R 0 6 2012 <br />SASNY RONMEHTA' <br />HEAITH DEPARTVE_KT <br />ACCEPTED BY: <br />EmpLoYEE# S> <br />DATE: �t v <br />ASSIGNED TO: f"Po- <br />EMPLOYEE#: L. -(o Lf <br />DATE: -1 - <br />Date Service Completed (if already completed): <br />SERVICE CODE: t /� < <br />PIE: <br />Fee Amount: -1 <)- , C-' <br />f Amount Paid <br />`03-75, ()-D <br />Payment t Date <br />(o11 v <br />Payment Type V 15 �, <br />Invoice # <br />Check # <br />Received By: <br />EHD48-02-025 31 J-0 JG- <br />SR FORM (Golder! Rod) n / <br />REVISED 11/17!2003 `\✓ <br />