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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 />;�ti�jl mc�,�/bc� )mP4 c�'�<i� <br />SERVICE REQUEST # <br />srpilc �crnk is rvt�, �eCJ e 15�>Jh <br />PHONE# ExT. <br />HOME or AILING ADDRESS <br />qq- <br />FOR INSPECTION. <br />CITY <br />/' STATE ZIP <br />OWNER/ OPERATO <br />ACCEPTED BY: <br />EMPLOYEE #: <br />-SL10- <br />ASSIGNED TO: �� - I �j <br />EMPLOYEE #: <br />CHECK if BILLING ADDRESS <br />FACILITY Na <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />O� <br />SITE ADDRESS ^ <br />Fee Amount: ,,$'67DL <br />Fj^ <br />'/,/� <br />Payment Type t 5A- <br />Invoice # <br />a <br />�s ZZU <br />L Street Number <br />DI—tion <br />Received By: <br />// <br />t/ �5tree Name " <br />ZI Code <br />HOME or MAILING ADDRESS ADDRESS (If Diffe elnt, f/roQm� Se Address) <br />' <br />L J <br />Vv [ <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />j t/l <br />PHONE #1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />�731�1 <br />PHONE#2 <br />( ) <br />ExT• <br />BOS DISTRICT <br />9 11 <br />LOCATION CODE <br />qq <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />i <br />;�ti�jl mc�,�/bc� )mP4 c�'�<i� <br />BUSINESS N E <br />srpilc �crnk is rvt�, �eCJ e 15�>Jh <br />PHONE# ExT. <br />HOME or AILING ADDRESS <br />Fax # <br />FOR INSPECTION. <br />CITY <br />/' STATE ZIP <br />48 HOUR NOTICE <br />ACCEPTED BY: <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, STAT d FEDE L laws. r,, <br />APPLICANT'S SIGNATURE: D-1 WATE: — I6— a <br />PROPERTY/ BUSINESS OWNER OPE OR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ T <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Ti r <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper sqp. aced a�)j} 2 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental A a s s �{{ <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ztA*FJ 1j6iRi68UU.INTY <br />provided to me or my representative. ENVIRONMENTAL <br />TYPE OF SERVICE REQUESTED: G''f I � CDi < <J,'vi7 6C S P. �I (, to. )A, <br />EPARTM <br />C, C d'^' t I Le 0I r <br />COMMENTS: II eJynl S�oOsaOd� nl�►CG°}t'S <br />SC;p i �' '� ► s Cpt,� <br />ks <br />;�ti�jl mc�,�/bc� )mP4 c�'�<i� <br />U y c��Jc►►'��br- c4 -?10, Ste, <br />srpilc �crnk is rvt�, �eCJ e 15�>Jh <br />. <br />CALL(209)953-7697 <br />FOR INSPECTION. <br />48 HOUR NOTICE <br />ACCEPTED BY: <br />EMPLOYEE #: <br />EQUIRED. f <br />4A <br />ASSIGNED TO: �� - I �j <br />EMPLOYEE #: <br />DATE: 66 1 <br />4 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />O� <br />11 P / E: 01 C) <br />Fee Amount: ,,$'67DL <br />Amount Paid <br />Payment Date ( <br />I <br />Payment Type t 5A- <br />Invoice # <br />�k # I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />VT <br />