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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />E✓ <br />L . SF�VICE REQUEST # <br />Q ZZi 5 �c1� <br />PHONE# EXT' <br />J�`�� <br />F -5-1 PEN /LEL <br />FAX # <br />(A(�DDRESS <br />V ' 37,q4— <br />v V <br />OWNER i OPERATOR <br />Cl <br />CITY <br />STATE 14A ZIP 5-3,e / <br />/Y75 . L A V <br />� COI L /N <br />CHECK If BILLING ADDRESS Er <br />FACILITY NAME <br />DATE: <br />SITE ADDRESS 32-14J <br />ASSIGNED TO: <br />/Yj O/lE//V 1q C%- <br />STo c6cTo �( <br />Y5 -204 <br />Street Numbe <br />Direction <br />Street Name <br />SERVICE CODE:I —Z <br />C ity, <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />pC� Amount P <br />3b (� Payment Date S�7 <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />STATE ZIP <br />gk <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # F0 <br />('-o V 47t�-0oi <br />/C'?',/-/ao - / <br />MAY <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICTIrpCATION C Q <br />'qQY/ty <br />CONTRACTOR / SERVICE REQUESTOR .4;MLTHDFp RNTq� n' <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />/\l <br />E✓ <br />BUSINESS NAME <br />Q ZZi 5 �c1� <br />PHONE# EXT' <br />J�`�� <br />HOME or MAI G <br />FAX # <br />(A(�DDRESS <br />V ' 37,q4— <br />Cl <br />CITY <br />STATE 14A ZIP 5-3,e / <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 ENVIRONME,NTAI.. HEALTli DEPARTMEN"I' 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 certity that 1 have prepared this aff Iication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard S ATE and law's. <br />APPLICANT'S SIGNATURE: DATE::oZ7��O <br />PROPERTY/ BI SINESS OWNER❑ OPERATO / MANAGER ❑luthorization <br />OTHER AUTHORIZED AGENT CI <br />IfAPPLIC'f NT is not the BILLING PARTY proof of 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 ENViRONMFNTAL HEAL. -m 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:6UgFAj�Fs <br />c� ONT�Ep.�►'��� <br />O P!� <br />E✓ <br />COMMENTS: �Np t t� <br />Q ZZi 5 �c1� <br />\ <br />Q�i�tdl <br />J�`�� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />Cy .�� <br />L <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:I —Z <br />PIE: <br />U3 <br />Fee Amount: <br />pC� Amount P <br />3b (� Payment Date S�7 <br />Payment Type '�' <br />Invoice # <br />Check # 3� <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />tel./ <br />