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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH4EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />REC�1V�� <br />FACILITY ID # <br />SERVICE REQUEST # <br />SA e4 RONUINENTXE9T <br />606 ZZ2:2? <br />OWNER/ OPERATOR <br />EMPLOYEE #:DATE: <br />O►d� � t �� <br />ICOM Gr <br />CHECK If BILLING ADDRESS <br />b <br />FACILITY NAME <br />DATE: / <br />Date Service Complete f beady complete <br />J <br />SERVICE CODE: <br />P 1 E:�' 3( <br />SITE ADDRESS 'tA <br />I <br />� �C�q v ` tti <br />i9 -t-. <br />� kNL�p fr\ <br />SZO 2_ <br />-3 LA 5 Street Number Direction <br />Street Name <br />Check # 0� '1 = 13& 1 °t'- <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />O O <br />3O$1"7 <br />S . <br />Street Number <br />Streetet Name <br />CITY <br />\��►cS <br />STATE ZIP <br />—T'7L '1 S 20 Z <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />U(YNTKAU 1'UK / SE'KVI-Uh KLIIJ)ULNIUK <br />REQUESTOR <br />CHECK If BILLING ADDRESS UY <br />BUSINESS K' A`•Yc` _ PHONE # EXT. <br />7,a. -k-- 'El.a v IL rot t t kE114--A k S��u .c.%—F-- S. , tic Cl►lo —1010 <br />HOME or MAILING ADDRESS FAX # <br />B S16 — l O ♦ \ <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: .��!�`_. �_ DATE:\—�Ln�f-���C� <br />PROPERTY/ BUSINESS OWNER [3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 21 -�i yAp� `1 T \q�0.g,� <br />IfAPPI.ICANT is not the BILLING PARTY. nroofofauthori7ation t0 sivan is reauired 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. PAYMEN" <br />TYPE OF SERVICE REQUESTED: US%��7�0 /% <br />REC�1V�� <br />COMMENTS: <br />-Ju lu <br />►lOv 1 <br />SA e4 RONUINENTXE9T <br />HEALTH DEpAATM <br />ACCEPTED BY: <br />EMPLOYEE #:DATE: <br />/,///v <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: / <br />Date Service Complete f beady complete <br />SERVICE CODE: <br />P 1 E:�' 3( <br />Fee Amount: dw <br />Amount Paid <br />'931'('.0D <br />Payment Date Wr 7 l -0 <br />Payment Type� t <br />Invoice # <br />Check # 0� '1 = 13& 1 °t'- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />