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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />((,� jj ,�,, �j <br />(iLIL ✓L� L. Li�%.Q CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />� ca S A qw <br /># ExT <br />� R <br />HOME or MAILING ADDRESS � � � <br />� �� � � <br />ONERI OPERATOR <br />CITY l OC CTO <br />STATE zip <br />n I O 6ge <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />?0 <br />2% <br />h Ero <br />SITE A S <br />I <br />`f <br />Ullv Cod <br />Ni-tDP4COJn <br />Street Number <br />Direction <br />Street <br />Name <br />DATE: I / N <br />ASSIGNED TO: <br />HOME or MAILING.DDRESS(if Different from Site Address) <br />S�j 1'-I <br />��V-\-U� A _o - <br />1' <br />Date Service Completed (if already completed):-SERV <br />ompleted):.VICE <br />Street Number <br />CODE: ��' <br />Street He <br />CITY S bC 1 �o Ili <br />STATE <br />^ zip qlj <br />CA l L <br />PHONE #1 E'R <br />(ao'7 ) <br />APN # <br />Payment Type L% <br />LAND USE APPPLLIIORATION # <br />PHONE#2 En. <br />` <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />I r IGLYZI //N, <br />((,� jj ,�,, �j <br />(iLIL ✓L� L. Li�%.Q CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />ISS <br />� ca S A qw <br /># ExT <br />� R <br />HOME or MAILING ADDRESS � � � <br />� �� � � <br />(AX # ) <br />CITY l OC CTO <br />STATE 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 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. [00C.? <br />1 5� <br />APPLICANT'S SIGNATURE: v r /aY (Gl �J eAi ct lO 0 e.% DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />V'APPL/CAA'T is not the BILLING PARTY proof of authorization to 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 soots as it is available and at the same time It is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />Q <br />Vekldt h WIS <br />ed 7� <br />M <br />COMMENTS: yr v UAIX <br />LCI(-- <br />elv 4 <br />DSC 03 <br />?0 <br />2% <br />h Ero <br />Ullv Cod <br />Ni-tDP4COJn <br />ACCEPTED BY: 40P <br />EMPLOYEE #: b 2 (3 <br />DATE: I / N <br />ASSIGNED TO: <br />EMPLOYEE <br />#: Q � <br />1 DATE: <br />Date Service Completed (if already completed):-SERV <br />ompleted):.VICE <br />CODE: ��' <br />P / E: <br />Fee Amount: 1� <br />Amount Paid <br />ebb <br />Payment Date 3 Z <br />Payment Type L% <br />Invoice # <br />Check # / <br />` <br />Rece' ed By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Q ogko <br />SR FORM (Golden Rod) <br />