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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property r <br />CHECK if BILLING ADDRESS E] <br />FACILITY ID # <br />REQUEST # <br />,I <br />Zl dY1 <br />� � <br />FAX# <br />CITY I-1 y <br />LRV6E <br />OWNER/ OPERATOR�� <br />/�rr <br />a v e' - <br />CHECK If BILLING ADDRESS <br />FACILITY <br />SITE AD RES 7 <br />�) G <br />��r <br />�i�Ci� <br />j(/ (C}Y?17 r6et u er <br />Direction <br />Street Name <br />Z od <br />HOME MAI GCADDR S (If Differ t from S' e/A�ddress <br />/Or <br />/� ^��1� <br />/y�j <br />(ti / / ✓SN N mber <br />Street Name <br />CITY � _ <br />STAT ZIP <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR c <br />Y C(Q�J� C C1l'Gt1J <br />CHECK if BILLING ADDRESS E] <br />BUSINESSAI1�E` <br />l' <br />PHONE # p EXT. <br />'/ ) 0�;? & <br />OME�orr M LING A ESS <br />7 L <br />� � <br />FAX# <br />CITY I-1 y <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, S ATE and FEDERAL laws. <br />f ��. a � _ 7 <br />APPLICANT'S SIGNATU 2tl✓ DATE: , �" �"�� <br />PROPERTY / BUSINESS OWNE PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ElIfAPPLICANTi, of the BILLING PARTY, proof of authorization to sign is required Tir ��������CC <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper�y lo�'c`'�tPt�°a9P <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environment I/ it <br />inforation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t e m n s <br />m <br />provided to me or my representative. SAN JOAQUIN COON <br />wo 19 <br />TYPE OF SER/VICE REQUESTED: <br />HEALTH DEPART EN <br />COMMENTS: Jef,�y 1k,f sink hc,s l6een eGppt(-, v"4e' needs to be cG,ppeCJ G,nd Wc15-r: ooiei <br />nFeds tD 6e C41ppvd, s��in% Gtrtlr�s 1n to sol/ <br />okay -� 51JY� ce14I/lerAf,' O[ r0CeUe1V �t leVeJY�%�In� CALL(209)953-7691 <br />/ FOR INSPECTION. <br />i5 CG. ppb - 24-HOUR NOTICE <br />II REQUIRED. <br />ACCEPTED BY: L� EMPLOYEE #: DATE: �;1 / f,%� <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): 2 10 Z Z SERVICE CODE:) P / E: a d a <br />Fee Amount: s Amount Paid ,� `S� 2— _ Payment Date fifl Z� 2 - <br />Payment <br />Payment Type Invoice # C4ec—k # 3 g 2 Y b Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />