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SAN JOAQUIII COUNTY ENVIRONMENTAL HEALTH _,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />S • 0 q 6 <br />SERVICE REQUEST # <br />5 ,Cio,f)772 6 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS '2)-tc)c-, <br />Street Number Number Direction <br />N ,2, <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 ExT. BOS DISTRICT _ LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS P <br />..,,,..) ,s- \.t.ve___,-' .5- <br />BUSINESS NAME PHONE <br />C-‘) e. C-.1 \ :() \ C.A-s,,.\te- , \.(•Z \ --5e- \A ( <br /># <br />( 7-e'cl) `ci 6i - ..'S1,--f- <br />EXT. <br />HOmE or MAiuNG ADDRESS <br />10 rin , v-c-.A‘ ,,,,vt_... 9‘A <br />- FAX # <br />(1-orA ) st-t s. <br />crry ,--\ STATE <br />L 1- <br />ZIP <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: <br /> <br />DATE: —1- L — pc( <br /> <br />PROPERTY! BUSINESS OWNER El OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT GI <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />C. '-x\c c..%rr\-( <br />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. <br />TYPE OF SERVICE REQUESTED: eie_c_ )14 &-...-4......c...7-7( g.....c.,,c( 0,0 ez___ A___54,-.) c...04-iE C/C_ <br />COMMENTS: <br />ACCEPTED BY: e, 4......i. tiG_I ,....44 EMPLOYEE #: 0 g 2" <br />ASSIGNED TO: Pie .4 a-04- 'a- 04 EMPLOYEE #: <br />DATE: 7 1 afo; <br />DATE: 7/24-0 <br />Date Service Completed (if already completed): SERVICE CODE: 5-z_2_ PIE: <br />Fee Amount:4 ...1(o , lyt) Amount Paid 'a ...( D . 0 -c-) Payment Date 7/ <br />'7 <br />1 <br />Payment Payment Type Invoice # Check # 3 1 1,, „ 1 i Received gy: ---te-e___ <br />END 48-02-025 <br />REVISED 11/17/2003 <br />050 S <br />SR FORM (Golden Rod)