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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br />SERVICE REQUEST <br />Business or Property <br />b� <br />FACILITY ID # <br />bUl3la�l <br />SERVICE REQUEST # <br />Seo$ 3�� <br />I OPERATOR <br />l�aiviH4 <br />FFAaLr7y <br />P. /�ecove <br />CHECK If BILLING ADDRESS 0 <br />AME //_ /G <br />Aja /Gt <br />CITY„ /ie *-d <br />�G2(�"'e/� <br />$IE ADDRESS 14&N <br />SMal Number <br />Dlracaon <br />C/u ' eve <br />Shell Nanw <br />HEALTH DEPARTME <br />O <br />HOME or MAIUNG ADDRESS (R Different from Stle Address)�� Sbeet Nmnber <br />Cm LUC ILt�r� <br />STATE �r� ZIP /J g <br />PHONE #1 <br />/� &Y-7/ Exr. <br />(ul -(/S <br />APN s <br />LANDUSEAPPLICATION # <br />PHONES 6r. <br />EMPLOYEE#: <br />ENDS DISTRICT <br />LOCATION CODE <br />(YINTRAfTnu / RF.RViCF RF.OUESTOR <br />REQUESTOR <br />CNECKif& <br />BUSINESS NAME I if W /e <br />/(A veivhPNDNEi <br />5 <br />--t <br />HOME or MARING ADDRESS <br />o i ox <br />g <br />FAst <br />( , <br />CITY„ /ie *-d <br />STATE LP 67 SZ 7 <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 Ibis 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 j <br />APPLICANT'S SIGNATURE: /.f.1�7���� e JV7• /Y Ol-e� DATE: '41Z O`ZQZ—/ <br />PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />1fAFPLjCANT is not the BxU1yG PIRTr. proof ojauthorization to sign is required Tule <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/We-'assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thIp, t <br />IV <br />provided to me or my representative. Rec rn <br />TYPE OF SERVICE REQUEstro: <br />SR FORM (Golden Rod) <br />REVISED 1 111 7/2 0 0 3 <br />� 01 <br />ColarExts: <br />�l/(QL1� ftT OWh�vShr�� <br />//�Is14%CC17bY <br />q <br />?OZ <br />SAN JOAQUIN <br />ENVIRONMENTAL <br />/ <br />HEALTH DEPARTME <br />ACCEPTED BY: ` <br />EMPLOYEE #: <br />I 22ASSIGNED <br />TO: <br />EMPLOYEE#: <br />qDATE: <br />UTE:Date <br />Service Completed (ff already completed): <br />SERVICE CODE: <br />PIE; I N <br />Fee Amount <br />-00 <br />1 Amount Pal ` D�) <br />Payment Date <br />/ <br />/b <br />Payment Type <br />Invoice # <br />Check # <br />[� <br />Receive By: <br />EHD 48-02-M <br />SR FORM (Golden Rod) <br />REVISED 1 111 7/2 0 0 3 <br />� 01 <br />Ty <br />