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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME Srec- „ t �GQ �5 Y <br />FACILITY ID # <br />SERVICE REQUEST # <br />seine+ <br />CITY _ / L _ STA ZIP 9 <br />ACCEPTED BY: 1ACI <br />S �3� <br />u r <br />y <br />0 <br />DATE: <br />fnn <br />ASSIGNED TO: <br />OWNER/ OPERATOR <br />•may. <br />CHECK if BILLING ADDRESS IL.r, <br />FACILITY NAME <br />eG Sauce +'qcoss l u <br />SER VICE CODE: O� <br />SITE ADDRESS 912- <br />P/E:I�(]2 <br />b v!Y W Iv a l <br />J " <br />Amount Pai/S <br />lA-ifTh/� <br />L� L'CU 1 <br />�ZI Z <br />Street Number <br />Direction <br />J Street Nama <br />Check # ��(]S�� <br />ZI Coda <br />HOME or (NAILING ADDRESS (If Different from Site Address) <br />cic!% Street Number <br />Street Name <br />CITY !' <br />SZATE ZIP <br />(jO q <br />PHONE#11 Ems. <br />APN # <br />LAND USE APPLICATION # <br />(209) 42-3—$'1?q g <br />PHONE #2 En. <br />1 ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR SLr.-U or-` Nz <br />(� CHECK if BILLING ADDRESS <br />BUSINESS NAME Srec- „ t �GQ �5 Y <br />PHI NE# —9� EXT. <br />H MEor AILINGADDRES <br />v! Cin✓en tsl G <br />FAX# <br />c 1 <br />CITY _ / L _ STA ZIP 9 <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: S DATE. <br />PROPERTY/ BUSINESS OWNED- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />lfAPPLICAArTis not the B7LLINGPARTY 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 aii}je_58me time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />Fj <br />COMMENTS: <br />8 20?2 <br />JOAQ NCID <br />H � o NMEN <br />ACCEPTED BY: 1ACI <br />EMPLOYEE #: <br />y <br />0 <br />DATE: <br />fnn <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: ZD <br />Date Service Comple d (if already completed): <br />SER VICE CODE: O� <br />P/E:I�(]2 <br />Fee Amount:it u 'QU <br />Amount Pai/S <br />oo <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # ��(]S�� <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />