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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE # Ea. <br />FACILITY ID # <br />FAx # <br />SERVICE REQUEST # <br />Zo <br />r fl �b�Ze3oq <br />S <br />�5 <br />OWNER /OPERATOR <br />NTM <br />ACCEPTED BY: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: <br />` <br />ASSIGNED TO: �W��V y-�^�e <br />EMPLOYEE#: <br />V <br />IS \2 <br />SITE ADDRESS (Io2 C <br />S <br />SCVCI `C� n Q4�7 5TC.` <br />P/E: bO3 <br />^V. <br />Amount Paid /sa,�� <br />CI ,4 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />LI <br />e7l/ ri f—e!� <br />Street Number <br />Street Name <br />CITY /`% - / <br />STATE <br />7 ZIP <br />C✓- <br />rZ/O <br />PHONE #1 <br />Ea. <br />APN # <br />LAND USE APPLICATION # <br />(2oW 509 c),1119 <br />i <br />PHONE #277 <br />Ea. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) O S <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Ea. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY 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 <br />COUNTY Ordinance Coder, Standards, STATE and FEDERAL laws. , <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/ MANAGER <br />If APPLICANT is not the BILLING PARTY proof of <br />be perfo ed will be done in accordance with all SAN JOAQUIN <br />/ DATE: 161211�-' <br />THE AUTHORIzEn AGENT ❑ <br />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 t0 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 />Dwr._ _ <br />TYPE OF SERVICE REQUESTED: <br />1 <br />COMMENTS: <br />guiva <br />JAN <br />Q° c --"T <br />Zo <br />71 t o POUIV <br />qR� <br />NTM <br />ACCEPTED BY: <br />EMPLOYEE #: 3 <br />DATE: <br />` <br />ASSIGNED TO: �W��V y-�^�e <br />EMPLOYEE#: <br />DATE: 22 <br />Date Service Completed (if already completed): <br />' _ S_ Z 2 <br />SERVICE CODE: O(o ` <br />P/E: bO3 <br />Fee Amount: 1 S2_ <br />Amount Paid /sa,�� <br />Payment Date 2� <br />Payment Type <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD r W5 J "� SR FORM (Golden Rod) <br />REVISEDSED 11/17/2003 6 <br />11/1IY <br />