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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME ,(� 1�1 t ) Ac1. <br />c71 <br />SERVICE REQUEST # <br />+QeSf61t4-r aolL <br />FACCPm2��9 <br />SlZmm865(o(a <br />OWNER / OPERATOR i <br />1111 <br />CHECK If BILLING ADDRESS� <br />FACILITY NAME •,(� 1 C�t�r <br />\J f\iJ �U�� <br />, <br />,(,.SITE <br />(� <br />!VS'�0C— <br />I <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />? Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />41�Z ed r�\VL' <br />„d <br />Payment Date;301 2 <br />W:r tStreet Number <br />-40 eceivedBy:WWI <br />Street Name <br />CITY / �t LK <br />STATE if ZIP �5 � <br />PHONE#1 Ea . <br />APN # <br />LAND USE APPLICATION # <br />(tiZ)1\) NSI ciz-71 <br />PHONE #2 Ear.I <br />( ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR OO•• /' 1— o� l 1 <br />(' I l /-% , L- p `J y <br />CHECK if BILLING AOORESSO <br />BUSINESS NAME ,(� 1�1 t ) Ac1. <br />c71 <br />Mqk 3 0 <br />PHONE# o+ (� ExT. <br />`i.� "� —7-7 <br />H MEOr MAILING ADDRESS, - , <br />Z N• PUc c ,f2• <br />FAX# <br />( ) <br />CITY ' Ct - _��� <br />STATE CF LP L\'�-�34- <br />BILLING ACKNOWLEDGEMENT: 1, 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 donein accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE d FEDERAL laws. /'y <br />APPLICANT'S SIGNATURE: / DATE: J 1 o 1-1-3 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the 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. p <br />TYPE OF SERVICE REQUESTED: C)rlftiZ <br />COMMENTS: <br />Mqk 3 0 <br />QAQUI <br />N COUry TY <br />ElV <br />HEALTH OA00EP�r'NS'N7' <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: %5� <br />Amount Paid <br />Payment Date;301 2 <br />Payment Type <br />Invoice#00 <br />-40 eceivedBy:WWI <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />