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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />JLu /' S ✓'� <br />FACILITY ID # <br />BUSINESS NA /� / <br />6L <br />SERVICE REQUEST # <br />S(�UD <br />OWNER TOR// <br />C / , / <br />V1 IC 7 <br />CHECK If BILLING ADDRESS <br />FACILITY NA tE r�� <br />( # <br />sH - 7 tenet <br />LL Street Number <br />Direction <br />y/D reel Name <br />Cll <br />�L Code <br />HOL�'LVDO/If 9ffernt f it Adss) <br />L4, Street <br />L Street Number <br />1.4 C <br />Street Name <br />Cl /� <br />EL zip <br />SKEL <br />PHONE#1 EXr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CDOE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR' /) _ t w <br />C <br />CHECK If BILLING ADDRESS El <br />BUSINESS NA /� / <br />6L <br />�GCIYG <br />EXT <br />p"1 J'Z Z /O <br />HOME OrIL NG i�!rSS <br />3 <br />( # <br />CITY /i� <br />ST/�(� ZIP P <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 preps is application and <br />COUNTY Ordinance Codes landards. STATE and PK <br />APPLICANT'S SIGNATURE: <br />will be done in accordance with all SAN JOAQUIN <br />z/ /zo <br />PROPERTY / BUSINESS OWNER❑ - OPERATOR / MANAGER G OTHER AUTHORIZED AGENT ❑ <br />IJ'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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anndtat the raj Fjme it is <br />provided to me or my representative. rAYMC17 s <br />n <br />TYPE OF SERVICE REQUESTED: <br />�GCIYG <br />COMMENTS: <br />G <br />SEP at + r1 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HATH DEPARTMENT <br />ACCEPTED BY:RA <br />6 A, <br />rrA l./ <br />t5 <br />EMPLOYEE#: <br />DATE:21�1 <br />ASSIGNED TO: <br />1.4 C <br />EMPLOYEE #: D <br />DATE: 'T <br />Date Service Completed Jif already completed): <br />SERVICE CODE: <br />Fee Amount: <br />'VV <br />I Amount Paid <br />S <br />ayment Date <br />Z/ <br />Payment Type I <br />Invoice # <br /># 2 ?l. <br />Received By: <br />EHD SED 1111 ^g 0" 1a A I A SR FORM (Golden Rod) <br />REVISED 1017/2003 `v _ ` i lV <br />