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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CONTRACTOR I � � Y FACILITY ID # ADDRESS REQUEST # Q 2r7 e t7 ?3 [:ZSERVICE � l,1S. PHONE # 2°f1 55 (0 3 Exr, HOME or MAILING ADDRESS G.Oci� 'Pr FAx # ( ) OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ 2 DATE: 11 ASSIGNED TO: ��w EMPLOYEE #: 7jo CITY l.-t� �1 n Date Service Completed (if already completed): STATE C.. i ZIP FACILITY NAME �• �c�w�o�S BILLING ACKNOWLEDGEMENT: 14 the undersigned property or business owner, operator or authorized agent of Sam SITE ADDRESS 8 Q 1.+ i v associated with this proje Street Number Dlrectlon w Stree Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street N tuber Street Name CITY STATE ZIP PHONE #I EXT, APN # LAND USE APPLICATION # (700t ) 334, s3�y PHONE #2 EXT. BOS DISTRICT 11 LOCATION CODE (2a o1 ) SS(o • 318 1 e /SERVICE REQUESTOR REQUESTOR \"� I � � Y CHECK If BILLING ADDRESS �� ► \ Q 2r7 e t7 ?3 BUSINESS NAME li:k l,1S. PHONE # 2°f1 55 (0 3 Exr, HOME or MAILING ADDRESS G.Oci� 'Pr FAx # ( ) ACCEPTED BY: ISQn I S Ct)CW dlv �� 2 DATE: 11 ASSIGNED TO: ��w EMPLOYEE #: 7jo CITY l.-t� �1 n Date Service Completed (if already completed): STATE C.. i ZIP Fee Amount: 3 Amount Paid BILLING ACKNOWLEDGEMENT: 14 the undersigned property or business owner, operator or authorized agent of Sam acb-nowlcdee that all site and/or project specific ENVIRONMENTAL. HLALTH DFPARTMENT hourly charges associated with this proje or activity will be hilted to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN jOAQLI COUNTI' Ordincaue Codec, .SlcoulcH dsQSTATE and FFDF.RAL laws. APPLICANT'S SIGNATURE* DATE: PROPEIi'rY / BUSINESS Ow\F.RLJ OPERATOR / SIA\AGhR ❑ O'I'IIF.It AUTHORI7.F.D AGE\T ❑ Ir.1 PPLIC.LV1' i.c 1101 the BILLING PARTY proof of authorization to sign is requireO Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at t above site address, hereby authormize the release of any and all results, grotechnical data and/or environmental/site assessme inforation to the SAN JOAQUIN COUNT Y ENVIRONNIF,NTAL I IEALTH DLI'ART1v1ENT as soon as it is available and at the same time it provided to me or my representative. n_ TYPE OF SERVICE REQUESTED: SR FORM (Golden R EHU 48-02-025 REVISED 11/17/2003 � � Y COMMENTS: -ly^ / ✓41v O�I � J ?3 H'o►�l 201 E1GnrD P4C04/ A,y ACCEPTED BY: ISQn I S Ct)CW EMPLOYEE #:[%Z L DATE: 11 ASSIGNED TO: ��w EMPLOYEE #: 7jo DATE:&ft1 Z J n Date Service Completed (if already completed): SERVICE CODE: Q(o P I E: LA103 Fee Amount: 3 Amount Paid / 3� dry Payment Date 1 7 aq Payment Type Invoice # Check # 10(3. d Received By: .