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SAN JOAQUIIPUNTY ENVIRONMENTAL HEALTH IfARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />- <br />TYPE OF SERVICE REQUESTED: <br />FACILITY ID # <br />SERVICE REQUEST # <br />-S&e X6/1, f -7-- <br />D P-, <br />M <br />DATE: —7 C/ 10 1 <br />ASSIGNED TO: � TmAGk <br />EMPLOYEE #: � '' "Z Z <br />OWN / P T R Z� <br />h <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />, <br />�• <br />Payment Type Invoice # Check # Received By: <br />�IT D S t5 <br />C� <br />Street Number D�tion <br />t <br />Ity Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Add ) <br />C Street Number <br />Street Name <br />STATE ZIP <br />CINt- <br />W-)(Avl <br />PHONE #1 ExT� <br />APN # <br />LAND USE APPLICATION # <br />ExT' <br />PHONE #Z <br />BIDS DISTRICT <br />LOC D <br />( )1 <br />7 <br />CONTRACTOR/ SERVIUC KEVUEJ Otun cul -t <br />ENYIR � GOU <br />REQUESTOR CHECK if <br />PHON , EM' <br />BUSINESS NAME 1 7—'3-77 y— <br />HOM or MAILING A DRE FAX #� <br />CITY STATE Z9na� <br />BILLING ACKNOWLEDGEMENT: I, the u dersigned property or business owner, operatur ur autuui l— ar,--- ,. o , <br />acknowledge that all site and/or project C" is E IRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me o _ b siness as i ntified on this form. <br />I also certify that I have prepared thi p 'catio at the wo o be performed will be done in accoi dance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar , STA a EDERAL laws. 1 _ <br />APPLICANT'S SIGNATURE: DATE•' ��j <br />PROPERTY / BUSINESS OWNER❑ OPERAVIBR / MANAGER ❑ OTHER AUTHORIZED AGENTy <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 />Prvv►ucu w uia vi u,y .vy.. �... .•.... <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: �,` L S pu���� ` <br />(JL> <br />t�P�� t -�,, �►�� cow <br />ACCEPTED BY:EMPLOYEE <br />M <br />DATE: —7 C/ 10 1 <br />ASSIGNED TO: � TmAGk <br />EMPLOYEE #: � '' "Z Z <br />DATE: <br />Date Service Completed (if already com ieted): <br />SERVICE CODE: i% <br />P / E: <br />Fee Amount: ? ��® Amount Paid .37 S DD 1 Payment Date `/1 V1 4 <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />