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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business " PProperty <br />C� �2 <br />BUSINESS NAME t <br />FACILITY ID # <br />Fit O(960 7 0 0 <br />PHONE# ExT. <br />SERVICE E <br />Jp,00 S J 9 01 <br />OWNER / PERATOR° �, <br />g I�.�: L i -P\� <br />/1 <br />r t� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Q j� n 7 R'O r� � <br />Ct /f <br />I1-' <br />ASSIGNED TO: S • Ram 1 r e ^7 <br />SITE ADDRESS <br />StreetNumber <br />I Direction <br />�, N <br />gK- t i �/ am R' i <br />Street Name <br />P� I <br />cm, <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />PIE. I (0 O. <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 1 ExT• <br />/ V <br />APN # <br />Payment Type <br />LAND USE APPLICATION # <br />PHONE02 ExT• <br />Received By: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR ,^7 .�^ r <br />CHECK If BILLING ADGRESSO <br />BUSINESS NAME t <br />1- i /� <br />PHONE# ExT. <br />HOME Or MAILING ADDRESS <br />�)) J f el � �� V,,, M � I <br />vl � <br />FAX# <br />( ) <br />CITY /-r STATE i � YI ZIP , a - <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, STATE altd FEDERAL laws. <br />APPLICANT'S SIGNATURE: / DATE: <br />PROPERTY /BUSINESS OWNER L'9 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [3 <br />IfAPPL/CANT is not the BILL/NG PARTY, proof of authorization to sign is required Tide <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />infomtation 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:Consuli;ion <br />er <br />COMMENTS: <br />,D <br />r a 2 1021 <br />SAN Jg ONME I <br />F+4.TMOE NTAL <br />ACCEPTED BY: V. t 4P _Ira <br />EMPLOYEE #: G a 13 <br />DATE: 1`0 / 1 a a <br />ASSIGNED TO: S • Ram 1 r e ^7 <br />EMPLOYEE #: it o Q + <br />DATE: 10 / ! / .a / o <br />Date Service Completed (if already completed): <br />SERVICE CODE: O (D I <br />PIE. I (0 O. <br />Fee Amount: �f r G � <br />w J <br />Amount Paid <br />I `3 (p <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # /Lf� -J� <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Md <br />SR FORM (Golden Rod) <br />?�. 403v� 5 <br />