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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CONTRACTOR /SERVICE RF.OTTF,S <br />FACILITY ID # <br />BUSINESS IVAM <br />SERVICE REQUEST # <br />`s n, r PHONE # a � _t�2, �32EXTE <br />j c <br />HOME or MAILING�QD�F3F,S� <br />��P�Y�` �Q <br />�© L /6 <br />FAX# t� g�44 =; 00 <br />Llld <br />5 <br />OWNER /OPERATOR <br />STATE (C ZIP <br />CHECK if BILLING ADDRESS ❑ <br />/ <br />'9 1 VrGNA1'/-N% I "I� ev <br />f <br />na I <br />FACILITY NAME <br />EMPLOYEE #: <br />SITE ADDRESS <br />` <br />V / (�� <br />(`' %,(soh eo t�� d <br />Name EO <br />j�(�rL ���7 <br />l `lam F'jcity <br />Street umber Direction Stet <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Zi Code <br />CITY <br />Street Number <br />Street Name <br />EMPLOYEE #: <br />STATE Zip <br />PHONE #1 EXT <br />(q> qq3� �� <br />APN # <br />a5-�a�06�= <br />LAND USE APPLICATION # <br />PHONE #T EXT, <br />/r7)O�n'O <br />BOS DISTRICT <br />RP I( <br />LOCATION CODE <br />T[)R <br />C <br />SICCING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized. agent <br />-- <br />CHECK if BILLING ADDRESS <br />BUSINESS IVAM <br />l <br />Pa )3 a� <br />`s n, r PHONE # a � _t�2, �32EXTE <br />j c <br />HOME or MAILING�QD�F3F,S� <br />��P�Y�` �Q <br />�© L /6 <br />FAX# t� g�44 =; 00 <br />Llld <br />CITY C <br />no <br />STATE (C ZIP <br />of same, <br />acknov✓ledge 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 />APPLICANTaS SIGNATURE: <br />PR <br />�r" Com" V41� <br />OPERTY /BUSINESS OWNER❑ <br />OPERATOR /MANAGER OTHER AUTHORIZEDAGENT V <br />If APPLICANT isnot theBILLINGPARTY, proof OfauthoriZation to sign is required <br />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 SERVICE REQUESTED:�/�p��'!�y�f /F�+(1t 1)1lFS 6!'("1 4r; -,Z% �if/�'-,, C% �) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />=�''(,' <br />COM/M�ENT�S: �1�Q - Y � (t/Y, f Yo <br />M Cwe� <br />J e o V 0.j WI <br />���y � <br />.abt. <br />ao PI `I <br />�`vspa fDr n � I Qu <br />no <br />Sha n <br />�c-�nr <br />W��t l�`� b e <br />d <br />Ain <br />/ <br />'9 1 VrGNA1'/-N% I "I� ev <br />f <br />na I <br />CCEPTED Y: `C 4 <br />/ <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: 6 _l <br />EMPLOYEE #: <br />DATE: <br />/r7)O�n'O <br />Date Service Completed (if already completed): <br />SERVICE CODE: a� <br />P! E$ <br />Fee Amount:' Amount Paid d <br />Z <br />Payment Date <br />Payment Type J► , L Invoice # <br />Check# <br />-A• Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />