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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME� 1 C O� ue 1_ ` <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />W1 r S l PICNI-\ Fbv-o C \q �t ` <br />SERVICE REQUEST # <br />CITY V--CW� r,,PTATE ZIP <br />l� NVQ 125 <br />�D <br />'YoVP <br />OWNER / OPERATOR <br />202 Q <br />ML�(SSPt <br />tai <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �t� <br />. I�IGcztSITE <br />EMPLOYEE#: <br />DATE: <br />ADDRESS 11IWO <br />I� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:v�j <br />'T� <br />PIE: <br />(0U7) <br />1 <br />Amount Pal <br />Payment Date <br />Z2 - <br />Street Number Direction <br />Invoice # <br />S[reet Name <br />Receive By: <br />city <br />Zip Code!" <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />� 1 S\l r o <br />F t� 1L1 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />o �i SSG <br />PHONE#1 <br />Ea. <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />( ) <br />Ea. <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />N /1!LVSSP `Iv CHECK If BILLING ADDRESS <br />BUSINESS NAME� 1 C O� ue 1_ ` <br />PHONE # Ea. <br />HOME or MAILING ADDRESS <br />W1 r S l PICNI-\ Fbv-o C \q �t ` <br />FAz# <br />( ) <br />CITY V--CW� r,,PTATE 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT it 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 />e.. <br />TYPE OF SERVICE REQUESTED: <br />V <br />Vii <br />COMMENTS: <br />('i1�1Gt�- <br />l� NVQ 125 <br />�D <br />'YoVP <br />202 Q <br />fAQU/At CH� opt <br />yEACTv <br />ACCEPTED BY:\It <br />Y <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: I <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:v�j <br />PIE: <br />(0U7) <br />Fee Amount: lv/ 2, <br />Amount Pal <br />Payment Date <br />Z2 - <br />Payment <br />Payment Type, <br />Invoice # <br />Check # 1 <br />Receive By: <br />EHD 48-02-025 (y (r�(Q5r6� SR FORM (Golden Rod) <br />REVISED 11/17/2003L! 3 2`4 <br />