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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT C h \ <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />t//:2G.i,� Ca <br />�- <br />DATE: <br />D�� <br />OWNER / OPERATOR <br />/L\ (yiC C <br />L If BILLING ADDRESS <br />l.+f.e �t'tt <br />�fia(/ <br />0'ia&X II)i J <br />�HELK <br />l•W G <br />FACILITY NAME <br />Fee Amount: <br />(s-& — <br />SITEADDRESS <br />�� �eet <br />Payment Type <br />Invoice # <br />Street Numher <br />Dlrectlon <br />Name <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Differ in frgm <br />Site Address) <br />/ u <br />/VL <br />(1 C <br />Street Number <br />Street Nla�m-e <br />CITY <br />STATE �� ZIP��. a <br />PHONE #1 E <br />(10) y2s-OZSO <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z <br />�) C J7 L <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# Ems' <br />l <br />HOME or MAILING ADDRESS <br />FAX# <br />( I <br />CITY STATE ZIP <br />BHJLING 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 <br />COUNTY Ordinance Codes, Starpderda <br />SIGN <br />PROPERTY/ BUSINESS <br />IjAPPLICANT is not the <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />FERAL <br />l� DATE: <br />MANAGEROTHER AUTHORIZED AGENT ❑ <br />RAY proof uthorization 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 P <br />provided to me or my representative. <br />Abr.--- <br />TYPE OF SERVICE REQUESTED: �jtMPti� <br />--."Il fie <br />C <br />COMMENTS:ESC^ <br />12 9 <br />�1 6022 <br />Tr <br />ACCEPTED BY: <br />t//:2G.i,� Ca <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: — 2 - <br />Date Service Completed (if already completed): <br />Date <br />SERVICE CODE: <br />P /E: QZ <br />Fee Amount: <br />(s-& — <br />Amount Paid <br />Payment Date 11'2-1'2— Z <br />Payment Type <br />Invoice # <br />Eh� <br />a <br />Received By: <br />L/ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />