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05/05/2004 12:50 4640138 ENVIRONMENTAL H&AITH PAGE 01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � 1� <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQ EST 004 <br />/ <br />I <br />OWNER /OPERATOR <br />l!✓1 �v I vv �i7 Z /1 i <br />CHEM <br />FACILITY NAME <br />A) <br />FAX# <br />l �a�15"� I-- 73S <br />SITE ADDRESS '1J 3 O Ur <br />STATE zip 9 I / <br />-CA <br />W u P5400 1 <br />DATE: <br />Date Service Completed (if already completed: <br />. Strept Number <br />Direction <br />Street Name <br />Amount Paid <br />Ci <br />21,Cd, <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Invoice # <br />Street Number <br />Received By; <br />Street Name <br />CITY <br />STATE zip <br />PHONE #t EXT. <br />NO <br />LAN0 (ISE APPLICATION # <br />(53d <br />PHONE #2 Eat. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORI <br />1 idd � � /) �� z rC' <br />Illiii �f <br />CyECK If gILLIN {1DDR6 )Ski <br />BUSINESS NAME `n <br />I <br />I <br />PHONE# C EXT. <br />HOME or MAILING ADDRESS <br />(off 7 <br />EMPLOYEE #i: X <br />FAX# <br />l �a�15"� I-- 73S <br />CITY I ^ <br />STATE zip 9 I / <br />-CA <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 nd that the work to be performed will be done in accordance with all SAN JoAQu[N <br />COUNTY Ordinance Codes, Stand STATE an FEDERA la <br />1. 1 Al <br />APPLICANT'S SIGNATURE: DATE: 51 <br />PROPERTY / BUSINEss OWNER❑ OPERATOR / MA GER 6 OTHER AUTHORIZED AGENT / fi� C i <br />If/IPPGICAN?is not theBlll=PAR y. proof tru orization to sign is required Title <br />A.UT-RORIZATION TO RELEASE INFORMATIOlY: 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, geotecbn(cal 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 />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #i: X <br />DATE: 5— <br />ASSIGNED TO: <br />EMPLOYEE #: 5 —7 3 <br />DATE: <br />Date Service Completed (if already completed: <br />SFMCECODE: l� <br />PIE: 91 <br />Fee Amoynt: <br />Amount Paid <br />u t0� <br />Payment Date <br />Payment Type ., <br />Invoice # <br />Check# <br />Received By; <br />EHO 4"2-025 SR FORM (Golden Rod) <br />