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CIE NSO <br />'Q> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />t,3 i ia1 4 <br />SERVICE REQUEST <br />perty <br />y� �CA>C�1%I131 , <br />SERVICE REQUEST # <br />G F4 <br />COMMENTS: <br />L,�4 o!!!Fx74*1es � - •��- ,� �, ,�t-; ;. <br />ExT. <br />HOME or MAILING ADDRESS 3 9 <br />OWNER / OPERATOR _ <br />�v� �l �/ �r"�L' CHECK if BILLING ADDRESS <br />f _/ �1�./�! <br />'5"Ovaw I 'r// <br />/gn®Pd�C/'fi�`D® <br />FACILITY NAME C C/„I RI � %G t✓ (/� �'' J��v r��i� y G/7� e' ICBG L <br />CITY I STATECA <br />SITE ADDRESS I%,3 O <br />ZIP <br />C'ii %�i�'L AJi'ud:11 �1 /c?,D <br />74,01't7' <br />57-5377 <br />Street Number <br />'on <br />Street Name <br />Ci <br />Fee Amount: <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from §i Address) <br />Payment Date <br />° J Street Number <br />Street Name <br />Invoice # <br />CITY � STATE 2!P <br />G/ <br />Q �� <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />(.24) <br />;L 57 a <br />PHONE#2 ExT- <br />BOS DISTRICT <br />LOCATION CODE <br />f D <br />S <br />�\ 3 1 1,15 Lei 011 C� 4 <br />` <br />N VREQUESTOR <br />IS <br />CHECK if BILLING ADORES <br />BUSINESS NAMEPHONE# <br />r 5 UC.T 10 fi e. <br />COMMENTS: <br />L,�4 o!!!Fx74*1es � - •��- ,� �, ,�t-; ;. <br />ExT. <br />HOME or MAILING ADDRESS 3 9 <br />FAX# <br />r <br />CITY I STATECA <br />ZIP <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 thAwork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT and FEDERA <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER OT ,R AUTHORIZED AGENT 1771 <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 SERVICES REQUESTED: <br />COMMENTS: <br />L,�4 o!!!Fx74*1es � - •��- ,� �, ,�t-; ;. <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />