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SAN JOAQWOUNTY ENVIRONMENTAL HEALj&DF-P0JkTMENT <br />&g://�'ERVICE REQUEST <br />T e of usiness or Ornnarki <br />BUSINESS NAME <br />FACILITY <br />ID # <br />SERVICE RE UEST # <br />HOME or MAILING ADDRESS <br />2655 SIC, o—yi �) G <br />Lm Un <br />CITY / I STATE li zip qbX5 <br />EMPLOYEE #: 2 <br />OWNER / OPERATOR <br />ASSIGNED TO: <br />CHECK If BILLING ADDRESS <br />EMPLOYEE #: y <br />� <br />DATE: <br />FACILITY NAM Aonn <br />Mn,\ <br />SERVICE CODE: / ap <br />SITE ADDRESS 6� J�1��� <br />PIE: ?j3 <br />-�&J <br />a <br />C�S�� `-' <br />Street Number <br />Direction <br />t ►✓ Street Name <br />Cit <br />2i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) N t ^ <br />tJn <br />Ilr C- Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 � MAR # <br />MAR <br />LAND USE APPLICATION # <br />(20 <br />PHONE#2 <br />( ) <br />n SEI RVICE� <br />r it V <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORADDRESS <br />BUSINESS NAME <br />/Yl� t .. <br />C I`,J4 U <br />�CHj�ECK%'if�BILLING <br />( NE llS`l ,`Y MI Exr. <br />HOME or MAILING ADDRESS <br />2655 SIC, o—yi �) G <br />FAx <br />( ) I- 65M <br />CITY / I STATE li zip qbX5 <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 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: 6n oak J DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �Q J <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 5q ps-lft-R-T <br />,REQUEES�TjE�D: (,�p� fV <br />COMMENTS: ..r� �ONO�, t F.l t� Pf a�J ) All <br />ihc� St upgrac �iB�t�C- r.5• <br />tLGPvl he - 3` liar\ <br />U. J\ <br />ACCEPTED BY: <br />EMPLOYEE #: 2 <br />DATE: G <br />ASSIGNED TO: <br />EMPLOYEE #: y <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / ap <br />PIE: ?j3 <br />Fee Amount:j7i Amount Paid - Paymenf Date ° <br />Payment Type Invoice # Check # � Received By' <br />EHD 48-02-025 SR FORM (Golden Rod) <br />RFVISFn 11/17/2003 <br />