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SAN JOAQUITCOUNTY ENVIRONMENTAL HEALTHOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />S-rA `T (© /kJ <br />FACILITY ID # <br />A or) v 3 1(o <br />SERVICE REQUEST # <br />S 460 (,, 0 1-20 <br />OWNER / OPERATOR f \ /\ r I l e�—> �0 D <br />CHECK If BILLING ADDRESS <br />FACILITY NAME A n <br />SITE ADDRESS 5-74 4 <br />Street Nu ber <br />t_/ <br />it tion <br />� n rF / r` <br />/' O "V Street NaCme_ , U C�- <br />n <br />�/ <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PW #2 — EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTO / SERVICE REQUESTOR <br />REQUESTOR tTA <br />CHECK if BILLING ADDRESS 13 <br />a <br />BUSINESS NAMEJWE <br />�gEXTT.. <br />FAUX Co-> / <br />F f/�/ `i�w 4 O <br />- E t MAILING ADD S � CRr ,— /� <br />1/ r' (s I �j — <br />CITY `7 E (!:�-o STATE c ZIP 45:�- S <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: -7 26 eb <br />DATE' <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT El <br />/f APPL/CA 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. <br />TYPE OF SERVICE REQUESTED: <br />Y�EI <br />COMMENTS: QC -PG <br />1--64E �CLrIQ <br />r7,/ ?c F -t? <br />,i:,F'r"a"naN1 <br />ACCEPTEDIf <br />9r'17 EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: / 2— <br />DATE: <br />Date Service Completed (if al6ddy <br />completed): <br />SERVICE CODE: <br />700 <br />PIE: 'Z <br />v <br />Fee Amount: �J1 BCI <br />Amount Paid <br />�O <br />Payment Date ILO l b <br />Payment Type <br />Invoice # <br />Check # y2 b S Z <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Ail <br />