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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />reC,f <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME _ <br />PHONE # <br />[++-1 11) <br />r <br />ru Lb 1;/32 - <br />OWNER /OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME 3 V ` L <br />WM- <br />CITY C � STATE I!P <br />SITEADDRESS `t <br />C • <br />pIkkTu <br />EMPLOYEE #: <br />'k <br />52� <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: f <br />P I E: <br />1 A, Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( 264 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />( ) <br />Received By:, <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />reC,f <br />K` _ <br />CHECK if BILLING ADDRES AT <br />BUSINESS NAME _ <br />PHONE # <br />[++-1 11) <br />�I_/^� EEXT.( <br />UL <br />HOME or MAILING ADDRESS G5 1 .\ 1, 11 Opp ,ny; <br />W �l. w� 1v• \ UU <br />FAX# <br />( 24n)���tj�G. <br />CITY C � STATE I!P <br />ZIP `k5205 <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: lt4m wlkk DAvie E: <br />PROPERTY / BUSINESS OWNEROPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENTr S-tft• o .1 <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. <br />TYPE OF SERVICE REQUESTED:, <br />reC,f <br />CEIVED <br />COMMENTS: <br />• <br />15 2012 <br />JUN <br />SA'+.,OAQIIM COUNT' <br />EN'JIROr.acNYa'_ <br />• <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ��%Y/ /� <br />/t / / / <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />C <br />Ll <br />/) <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: f <br />P I E: <br />Fee Amount: <br />Amount Paid �']S -� ) <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By:, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />