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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST VICE REQUEST#SER <br /> FACILITY ID# if <br /> Type o,f Business or Property v_U 310 7 <br /> CHECK if BILLING SS <br /> OWNER 1 OPERATOR <br /> (( <br /> FAcs.mr NAME . AZI <br /> SITE ADDRESS 0(4 �,�E g <br /> A <br /> t Number Dire <br /> }{ONE or MAILING ADDRESS (if Different from Site Address) ree N <br /> Weld Number ZIP <br /> STATE <br /> CrrY 01 <br /> Exr. APN# LANo USE APPUCATIOW# <br /> �44� <br /> Bos DISTRICT LOCATION coos <br /> Exr. <br /> PtrotiE#2 ' <br /> ( 1 <br /> CONTRACTOR SERVICE REQUESTOR <br /> SCK if Rs nM ADDRES$1.� <br /> REQUESTOR A A ut. •44C4 ��1 , <br /> ti EXT. <br /> p1�NEfi <br /> BUSINESS NAMES, J F A v C C® w.r n w crt r . S o • g� _( <br /> FAX# <br /> HOME or MAILING ADDRESS r( t N� 4�.�� <br /> J STATE <br /> CITY S`ral.Al. ,'{t4` <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 HMTH 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 ® / <br /> APPLICANT'S SIGNATURE- // DATE: ` <br /> PROPERTY IBUSINESS OWNER® OPERATOR/MANAGER[3 OOTm tUTiOR=D o sign is 4�� �`G _Title <br /> If APPLlG;lNT is not the Bt1 LING PARTY.proof f <br /> AUTHORIZAated at the <br /> TION TO RELEASE INFORMATION:When applicable,1,the <br /> datoperator <br /> a and/or nviirohe property nmental/site�assessment <br /> above site address, hereby authorize the release of any and all results, g <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL H DEPARTMENT as soon as it is available and at the Sarna time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S7" <br /> COMMENTS: RECEIVED <br /> APR 15 2004 <br /> SAN JOAQUINUw� <br /> ENVIRONM NOTAL <br /> EMPLOYEE#: ®�j Z,( DATE: ,t <br /> ACCEPTED BY: �(,,_[�/�/t(l_�— <br /> EMPLOYEE M -73 M DATE: ( Q <br /> ASSIGNED TO: SERVICE CODE: t l t�p P 1 E: R-?.09 <br /> Date Service Completed (if already completed): <br /> t: • cJ,ep <br /> - �/•00 Payment Date //S/D y. <br /> Fee AmounAmount Paid <br /> # Check I? Received B . rllreR- <br /> • Payment Type ✓ Invoice • <br /> SR FORM(Golden <br /> EHD 48-02.025 <br /> oe�ncen��re7nnn� _ "- <br />