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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME_ <br />SERVICE REQUEST # <br />Re C <br />2-2- <br />HOME Or MAILING ADDRESS <br />� os342-0 <br />c ,` <br />1 I 1 <br />CITY STATE N , ZIP O <br />ht q TyoQ <br />OWNER / OPERATOR <br />MI� <br />q ��Y <br />ACCEPTED BY: C _ �S �_4 <br />t_b(fo <br />} If BILLING ADDRESS <br />FACILITY NAME <br />DATE: / T <br />l 7 <br />ASSIGNED TO: 1 ` y„ <br />EMPLOYEE#: <br />DATE: S—( _-)4 <br />SITE ADDRESS <br />l 7 <br />YJ• <br />KetUeMa� l�n� <br />todl CH <br />Fee Amount: (19,)-- <br />Sffolt N.r;i; <br />Direction <br />Payment Date <br />S <br />Payment Type <br />Zip Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check #j� �S� <br />Received By: <br />Street Nem Eer <br />Street Name <br />Cl <br />ry <br />STATE zip <br />0 " 1090/ b <br />PHONE#1 Ex'' <br />APN It LAND USE APPLICATION # <br />(110D91 <br />o58aH0+ <br />PHONE #2 EXT <br />I I <br />BOB DISTRICT <br />®t�f� <br />LOCAT N CODE <br />2 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />( CHECK It BILLING ADDRESS <br />BUSINESS NAME_ <br />PHONIES ExT. <br />�t 7�c 1 n <br />`D <br />MAY <br />HOME Or MAILING ADDRESS <br />FAX # <br />I D (?-k L D tv 0 <br />1 I 1 <br />CITY STATE N , ZIP O <br />BILLING ACKNOWLiDGEMENT: f, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN'r hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that 1 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. pp x ( DATe:� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/D'IANAGER❑ OTHER AUTHORIZED AGENT 11 <br />/,fjAPPL/C-ANT is nal the B/LLINU PARTY. proof of authorization to sign is required Title <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 Same time it is <br />provided to me or my representative. pw <br />TYPE OF SERVICE REQUESTED:Qt,tJ �G(JYI.t../ <br />w1Sv� f %�'✓1 <br />COMMENTS: <br />`D <br />MAY <br />�ro <br />ht q TyoQ <br />MI� <br />q ��Y <br />ACCEPTED BY: C _ �S �_4 <br />t_b(fo <br />EMPLOYEEM <br />DATE: / T <br />l 7 <br />ASSIGNED TO: 1 ` y„ <br />EMPLOYEE#: <br />DATE: S—( _-)4 <br />Date Service Completed (if already completed): <br />SERVILE CODE: <br />1 <br />P IE: (pl y <br />Fee Amount: (19,)-- <br />Amount Pa <br />. ,D. Od <br />Payment Date <br />S <br />Payment Type <br />Invoice # <br />Check #j� �S� <br />Received By: <br />EHD 48-02-025 ��p�p�t`_ <br />REVISED 11/17/2003Py� <br />SR FORM (Golden Rod) <br />