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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />REQUEST # <br />SERVICE REQUEST <br />gIA0V1}ion% fQ9t��Mp +;yt /K�nu� SubdiV�Si6� /d KA <br />ACCEPTED BY: <br />EMPLOYEE #: <br />S 1 d_ N "a( ALr C td ©rcke-rc9 <br />N/3 <br />"Sq 140 <br />OWNER/ OPERATOR <br />Date Service Completed (if already completed): <br />52 fo. rt'/'e J t n,4- Co <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />P / E: a o3 <br />SITE ADDRESS <br />Amount Paid 3� d <br />�t'�G �of <br />1%�%-I,�Ca <br />9SS.3.3(o <br />5V 5 Street Number <br />Direction <br />6ll <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS Different from Site Address) <br />pAY <br />/(If <br />Q>�T Q T �� Street Number <br />Street Name I <br />CITY <br />%%iQ/Jitc a e,4 p,�3T56 <br />STATE ZIP�' <br />PHONE #1 ExT. <br /># <br />LAND USE APPLICATION #Qu(Zo5) <br />TPN <br />SZ y-3a8o i .�Z <br />16-obo-0 I <br />2w <br />loo JOA,.5 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Se CCLY A ✓-eS 4nA,%%i C O . CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE# EXT. <br />5 .e.. C a a 2-9 <br />HOME or MAILING ADDRESS FAX # <br />1'-13 of E'c. f 1-4 13 ( ) +c•t; (2 ro rAuS110Ms-eo <br />CITY Q17%cu C/9 p3 <br />3:57/ STATE ZIP <br />X21 <br />Nr. <br />BILLING ACKNOWLEDGEMENT: 1, 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: ' cr 4 DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGEIX OTHER AUTHORIZED AGENT ❑ <br />/f APPLICANT is not the BILLING 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: R.Q-ViEhJ 540Fau SubSHrFaUt <br />gIA0V1}ion% fQ9t��Mp +;yt /K�nu� SubdiV�Si6� /d KA <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 1j <br />`Or <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />2s a I <br />Date Service Completed (if already completed): <br />SERVICE CODE: <. X13 <br />P / E: a o3 <br />Fee Amount: <br />I <br />Amount Paid 3� d <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # a <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />