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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAO0034-3o S (Z0 0r713Q2 <br /> OWNER/OPERATOR 1 n nnn <br /> F,�� f vII( 1/�� V1 0 1 �KhP leil1� CHECK if BILLINGADDRESSEI <br /> FACILITY NAME ff--- /rI` 1`U,�IT l v <br /> ,v�suv`L�,, G�s � � o-� <br /> %a o�►ES STo�1�ep�, ffchsa o <br /> r <br /> Street Number Direction Street Name io Code <br /> HOME Or MAILING ADDRESS (If Different from Site Addr SS) <br /> U �52D, <br /> 6 S U S l \C,� � Street Number Street Name <br /> CITY �C C _o/-V r STATE ZIP � S- <br /> I V a Z <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (ae ) Z a Seo — 030 -- l Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX <br /> ( ) <br /> CITY STATE 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA E and FEDERAL law <br /> APPLICANT'S SIGNATURE: f — q71" aQ I <br /> DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPE ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof Of authorization t0 sign iS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It Is provided to me Or <br /> my representative. P <br /> TYPE OF SERVICE 'Food <br /> ccmul ,�-�i fv) I��� <br /> COMMENTS: JA <br /> InN <br /> �Q.�..J ��✓�ti $qN 1 z0�5 <br /> UI N CGU <br /> HEALTIi .E rMENn' <br /> ACCEPTED BY: y^ EPAPLOYEE#: DATE: <br /> ASSIGNED TO: il"t ���7 /dI/h EMPLOYEE#: DATE: <br /> Date Service Completed (if already cot pleted): SERVICE CODE: PIE: Vb� <br /> Fee Amount: '3 _�—. Amount P ' b� Payment Date l� <br /> ayment Type Invoice# Check# �j'q i�/�-? Received B <br /> '-02" SR FORM(Golden Rod) <br />