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SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />I F <br />PHONE# ExT' <br />5800857 84 <br />OWNER/ OPERATO <br />CHECK if BILLING ADDRESS <br />FAX# <br />DATE: elI 7^ Z <br />FACILITY NAME <br />CITY STATE ZIP <br />I A o G- L 1) IRIS <br />SITE ADDRESS - <br />.'YiG �j. Og1tfNV`eY <br />Fee Amount: I r.1 <br />Amount Paid <br />$TOG V T 0 r- <br />Payment TypeInvoice <br />�J Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />or MAILING ADDRESS (If Different from Site Address) <br />HOMEpV E <br />Tr`t <br />Xy L; - lU % 1'= 1 N 417 <br />Street Number <br />Street Name <br />CITY <br />STATE <br />Q <br />r�ZIP <br />Va -\ <br />PHONE#1 Exr. <br />APN# <br />LAND USE APPLICATION# <br />( 20-4 I <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />_r <br />BUSINESS NAME <br />PHONE# ExT' <br />G- L 1) Yat YZ <br />DATE: II tc' 7-Z <br />1 .✓J <br />HOME or MAILING ADDRESS <br />FAX# <br />DATE: elI 7^ Z <br />( ) <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 or <br />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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: t \ <br />�,rp�cA� DA1'Fir Oct_ IS- as <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />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 environmentallsite 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. PAYenGAa <br />TYPE OF SERVICE REQUESTED: Food a hec <br />•T 1 <br />CEI <br />COMMENTS: <br />SEp 15 <br />[� ROLN DS N,HE CONAL <br />ACCEPTED BY: <br />v <br />EMPLOYEE#: !L/ <br />v <br />DATE: II tc' 7-Z <br />1 .✓J <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: elI 7^ Z <br />Date Service Com ted (if already Completed): <br />SERVICE CODE: <br />PI : <br />Fee Amount: I r.1 <br />Amount Paid <br />Payment Date Zy <br />Payment TypeInvoice <br /># . <br />Gheck <br />eived By: <br />v <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />