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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ali IS`� µ6� <br />r <br />v <br />FACILITY ID # <br />SERVICE REQUEST # <br />13 <br />FAX# <br />STATECA ZIP <br />FFA (Do 2.3 3 <br />S 0 <br />OWNER / OPERATOR <br />FIV V41 (t ! _� — -W <br />/ sY I —r J aLiLL� CHECK If BILLING AODRESS� <br />WPiv �V� lr) <br />FACILITY NAME FIP�W1H&S <br />SEJOAVtRQUTA/ COUNT <br />SITE ADDRESS ZA <br />/nLeR <br />woe— RV <br />Street Number <br />Direction <br />ACCEPTED BY: <br />Street Name <br />Cll <br />21 Cade <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />l L <br />p ✓l <br />DATE: <br />Street Number <br />Slreet Name <br />CITYCi'/��/� <br />Wa1/�i�•^s -�M' `JaT <br />STATE CA <br />A ZIP o�a3 S <br />PHONE #1 M # <br />`' APN <br />Fee Amount: <br />LAND USE APPPILICATION # <br />PHONE#2 Ev. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />l ?r� CHECK if BILLINGADDRES AZr <br />r <br />v <br />pNg#) Ezr. <br />l <br />FAX# <br />STATECA ZIP <br />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 Codes, Standards, STARE and FEDERAL laws/ <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER 13 <br />YAPPucavT ii <br />will be done in accordance with all SAN JOAQUIN <br />DATE: <br />OTHER AUTHORIZED AGENT ❑ <br />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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: V(>nA P an pf_– .— <br />COMMENTS: <br />Z0Z1 <br />SEJOAVtRQUTA/ COUNT <br />Mme` D@ AL <br />A T ela <br />ACCEPTED BY: <br />./ \ tet- <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO! v <br />\le U\ (31-1-01, <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: t��3 <br />P I E: 0\ <br />Fee Amount: <br />E� La <br />Amount Paid <br />Payment Date <br />at W <br />Payment Type, <br />Invoice # <br />I Check # <br />22 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />vv --b )V O <br />SR FORM (Golden Rod) <br />S <br />