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r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH JJEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY Ip # <br />COMMENTS: <br />SERVICE REQUEST # <br />R-ETAtL CAso c 11.t <br />RF�F' <br />2 9 200? <br />(08�%f <br />CITY <br />CITY _ S A E O <br />3e-00 5 -21--7-7 q <br />OWNER / OPERATOR <br />Q (.i 1 14- ST O (P A-RrV- �� �^ C _ <br />SAN JOAQUIN COUNTY <br />CHECK If BILLING ADDRESS <br />r <br />ENVIRONMENTAL <br />EALTN DEPARTMENT <br />FACILITY NAME V l (L � TC rQ1 Z- SAY <br />^ <br />!i <br />`� (v 1� t �J <br />Z f <br />EMPLOYEE #: 0 j <br />SITE ADDRESS <br />�,�/ <br />wt Ar l n( <br />S T- - <br />DATE: l( F -To ('1 - <br />• 2- c P C r.( <br />9 S 3 6 6 <br />/ S if 0 Street Number <br />Direction <br />Street <br />Name <br />7�9_cp � "i) <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />s E 5: T . <br />/-/ S-6 �- Street Number <br />Check # <br />Street Name <br />CITY r 2 VIA 0 <br />r <br />STATE C 4 ZIP 9 /S3 <br />`7 <br />PHONE #1 ExT• <br />gSC 0 <br />APN #LAND <br />��t- <br />O- Zl <br />USE APPLICATION # <br />PHONE #Z <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR f M t C " A, e4- W A, I- T—G-r-( <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME VJ A L - —" FI a i a (2, t a r p �1 C <br />COMMENTS: <br />PHONE # ExT' <br />916 <br />HOME or MAILING ADDRESS T� O B ®X Z <br />F <br />RF�F' <br />2 9 200? <br />FAX# <br />(416 ) 3}3 _ t t'4- 1 - <br />CITY <br />CITY _ S A E O <br />STATE C A ZIP C1S6 q <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: /1 �Z / <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 53 C <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 />A <br />provided to me or my representative. us I A'1 6 /L�P4 t k"?-- <br />TYPE <br />2 <br />TYPE OF SERVICE REQUESTED:(� ( A'►�( j Z E U t 6t/i% <br />"/"f— <br />f—COMMENTS: <br />COMMENTS: <br />RF�F' <br />2 9 200? <br />NOv <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />EALTN DEPARTMENT <br />ACCEPTED BY: <br />`� (v 1� t �J <br />Z f <br />EMPLOYEE #: 0 j <br />DATE: t( 3 D 197 <br />ASSIGNED TO: <br />A 4 t D t <br />EMPLOYEE #: 2_6'7 Ct <br />DATE: l( F -To ('1 - <br />Date Service Completed (if already Completed): <br />SERVICE CODE: / �� �, <br />P / . Z 6 <br />Fee Amount: <br />7�9_cp � "i) <br />I Amount Paid ` <br />Payment Date <br />�� Z_ l O <br />Payment Type <br />U-1-"' <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />