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SAN JOAQu-4 COUNTY ENVIRONMENTAL HEALT.. DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NA E /, I(i}� <br />FACILITY ID # <br />F A 0000 891 <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />r� , /� <br />f I" <br />SSU Ht3vit <br />- - <br />CHECK It BILLING ADDRESS <br />FACILITY NAE t <br />SAN JOAQUIN COUNT' <br />-1 <br />Sff�URESS <br />Stmel Number <br />Direction <br />L, n <br />�JPST, Tv2%U W4A1) <br />Street Name <br />f <br />�C GI r cit <br />r <br />qJ�U� <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Date Service Comple d (if already completed): <br />STATE ZIP <br />PHONE #1 fir' <br />( I <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 F-aT- <br />( <br />Paid �,t O. 0 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />cwt �." T� CHECK IT BILLING ADDRESS <br />I <br />BUSINESS NA E /, I(i}� <br />PHONE # �� r (�' -7 <br />HOME or MAILING ADD ESS <br />FAX# <br />SSU Ht3vit <br />( I <br />CITY „ _ n STATE C 6 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 ET�)A <br />ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandardsEandrFEDERAL laws. <br />APPLICANT'S SIGNATURE: ' (4 DATE. <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT B tP%R O F yiYg,A�Ac , <br />IfAPPL/CANT is not the BILGING PARTY proof of authorization t0 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 SERVICE REQUESTED: <br />PAYM,ti,41 <br />pF=CnvEI] <br />COMMENTS: <br />R.J�Y�-tel <br />MAR 2 D 2DD9 <br />SAN JOAQUIN COUNT' <br />-1 <br />ENVIRONMENTAL <br />HEALTH [)IfpARI MEN <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: Q <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Comple d (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount <br />Paid �,t O. 0 <br />Payment Date <br />3 4 <br />Payment Type <br />Invoice # <br />Check #7g <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />