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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />C go8 37 E <br />HOME Or MAILING ADDRESS <br />SERVICE REQUEST # <br />OWNER IO RATOR <br />�Ke-_� n. <br />��/ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE#: <br />SITE ADDRESS a Z59 <br />Street Number <br />Direction <br />Street Nama <br />EMPLOYEE #: <br />%®D <br />L <br />CityZI <br />DATE: Z �7 3 <br />/t <br />L�$Z /1,0 <br />I <br />Cotle <br />HOME or IYIAILING ADORE/5 /5 (If Different from Site Address) <br />22 4t/ %� i�C Street Number <br />SERVICE CODE: <br />Street Name <br />CITY 6 7L-) _ / <br />(J V /� <br />STATE ^ ^ <br />ZIP /)� •7 j JS-- <br />% C <br />PHONE #'I <br />(zoq) Svc 324C <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />BOS DISTRICT <br />Received By: <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE�O# <br />o�C <br />C go8 37 E <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 <br />COUNTY Ordinance Codes, Standards, E and EDis appli tine that the work to be performed will be done in accordance ith all SAN JOAQUIN <br />ERA�aws. <br />k <br />APPLICANT'S SIGNATURE: wro ✓✓ DATE: <br />PROPERTY/ BUSINESS OWNER❑ O 'BATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br />If APPLICANT 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 soon as it is available and at tk same time it is <br />provided to the or my representative. Vka�_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />�V <br />DEC <br />13 <br />.cA.� Cl 709/ <br />"NYV 2/ <br />44q <br />AIC <br />fOf R�M� ENTONn <br />ACCEPTED BY:. <br />EMPLOYEE#: <br />DATE: I 2/ <br />ASSIGNED TO: <br />/ �%) <br />vv <br />EMPLOYEE #: <br />DATE: Z �7 3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: Z( ) <br />Amount Paid <br />I l r <br />Payment Date I <br />Payment Type <br />Invoice # .Cheek <br />'7J .� �O <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />