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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME rJ�"`� <br />SERVICE REQUEST # <br />s D <br />> OWNER/ OPERATOR <br />WNER/OPERATORI eA(Y-a \ �� <br />Sv l//It <br />CHECK If BILLING ADDRESS <br />FACILITY NAEeM.�ES� <br />FA%# <br />( ) <br />CIN (/'I <br />S j�/�DDR Street Number <br />�1�/I <br />Direction <br />'(\'`Xf <br />ams". <br />a SIreMMSme <br />EMPLOYEE #: g��✓XV <br />DATE: t Z <br />0 <br />Date Service Completed (if already completed): <br />HOMEorMAILING ADDRESS (If Differe t from Site Address) <br />�Street Number <br />1 E. 1W I <br />Street Name <br />QU <br />CITY (p� �\ /!•At ,/� k ( <br />` r 1 <br />STATE r n ZIP <br />S <br />PHONE #1 ExT• <br />(Q Leo I <br />APN # <br />LAND USE` AP�P-tLIICATION # <br />Check # —/ 24 T <br />PHONE#2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />REQUESTOR1r n 1 " <br />,1 //1/ Y <br />C\ <br />m CHECK if BILLING AGGRE55O <br />�� n" t ^ <br />t//Al <br />BUSINESS NAME rJ�"`� <br />�D1, <br />PHONE# EXT. <br />HOME Or MAILING ADDRESSvI'\12 <br />`` <br />,n n 1 (�� �r�� <br />YV\ ,\v <br />FA%# <br />( ) <br />CIN (/'I <br />STATE ZIP C� <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 t apph tion and tha the o to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand sSTATJ and FEDE la s. <br />APPLICANT'S SIGNATURJr: DATE: c/ I <br />PROPERTY / BUSINESS OWNERN`K1' TOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BLLL/NG 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/sitee assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the s ,e it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 0� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: <br />MobiIt, Food <br />lean chew- <br />SAND 4102 <br />h�I <br /><TyO�P t <br />I ✓`n S . <br />ACCEPTED BY: ' (] Lk <br />�-Vl Vbt <br />EMPLOYEE #:liq ry) <br />DATE: tly P4 <br />ASSIGNED TO: <br />Gdnaoe <br />EMPLOYEE #: g��✓XV <br />DATE: t Z <br />0 <br />Date Service Completed (if already completed): <br />SERVICE CODE: i -3 <br />1 E. 1W I <br />Fee Amount:* <br />QU <br />Amount Pai 7�Dr ob <br />Payment Date <br />S <br />Payment Type 1 <br />Invoice # <br />Check # —/ 24 T <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />