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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />lC.� v%t+ CHECK if BILLING ADDRESS IT <br />FACILITY ID # <br />w+z120u i0,,-e?0,,-e� <br />� �dj, <br />/COOO�MtMENoT8S:: <br />. fr <br />- /.civ-�,• 6 <br />SERVICE REQUEST # <br />ROME or MAILING ADDRESS <br />4 t !� r'� � ! t •�� �4 <br />(Ax <br />CITY l/\ <br />• ZIP ^7 <br />' STATE CA, <br />OWNER/ OPERATOR <br />C <br />1�12FACILITY <br />r <br />CHECK if BILLING ADDRESS <br />NAME ,�1� �`y{ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />SITE ADD <br />-2— <br />Date Service Completed (if already completed): <br />7C- <br />7C-, ` <br />P 1 E <br />X12 ` ( -1 <br />' ea <br />3Z. —t� Street Number <br />pi—tion <br />Payment Type t,/ <br />Street Name <br />Received By: <br />ci <br />Zi Code <br />HQME or MAILING ADDRESS (If Different from Site Address) q <br />a_ i <br />L <br />Street Number <br />Street Name <br />CITY %�p� p„�,rte :. <br />l N j�► <br />/ <br />TA 4P2& 4 <br />/J'i Exr.API <br />PHONE #1 <br /># <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE4uESTOR zt-A4 �l � <br />lC.� v%t+ CHECK if BILLING ADDRESS IT <br />ivBUSINESS NAME <br />w+z120u i0,,-e?0,,-e� <br />� �dj, <br />/COOO�MtMENoT8S:: <br />. fr <br />- /.civ-�,• 6 <br />PHONE # Exs. <br />ROME or MAILING ADDRESS <br />4 t !� r'� � ! t •�� �4 <br />(Ax <br />CITY l/\ <br />• ZIP ^7 <br />' STATE CA, <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 to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, ,Standards, ATE and .FEDERAL laws. <br />APPLICANT'S SIGNATURE: f DATE: _ C + t <br />PROPERTY/ BITSINESS OWNER © OPERATOR/ MANAGER © OTHER AUTHORIZED AGENT �t <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tide <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 sante time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />YME <br />zgf lr"i0 m2 <br />e'r <br />/O�//0/-7/'0xr��r <br />ive!e[vt�4axma, l <br />%/9/01- V1 <br />jS-), Zoos <br />w+z120u i0,,-e?0,,-e� <br />� �dj, <br />/COOO�MtMENoT8S:: <br />. fr <br />- /.civ-�,• 6 <br />�l►//l/(J&- �Pr�dahYxr of uedl iZy/Get (/��-�� �ti-8,/�N-9� -l. jJ,r� �� <br />A< .'�AN <br />Y <br />tt.'jt3�dg-o�S�cr✓�SaH 8i'` �r� ,I�tr<�S°y ��rv-itiP,arV-11,, 9411--f6)-�.S MAROON ENTAL <br />N- <br />EAL <br />/0/1 d ' g� uy c, o„r rdtGr' ! � 11-f /4/- Iltts'/mt/ d /jJ fS-��7 <br />-fHDEPA T EIdT <br />CCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E <br />Fee Amount '4 3l5T oM <br />Amount Paid 3 <br />Payment Date 0 <br />0 <br />Payment Type t,/ <br />Invoice # Check # 9'3 •D <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />