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&SAN JOAQV COUNTY ENVIRONMENTAL HEALT41EPARTMENT <br />S VICE REQUEST <br />Type of Business or Property <br />rJ XIS 7 t'n <br />�! FACILITY ID # <br />(+ 6o'o 0 7 -?q <br />SERVICE REQUEST # <br />f G Z � <br />OWNER / OPERATOR <br />'e YYIp a Yi Cp Ci.. <br />CHECK IN BILLING ADDRESS <br />FACILITY NAME <br />(AX# ) —3/ <br />CITY <br />-03 <br />• <br />SIT ADDRESS <br />Street Number Dion <br />�� Street Name <br />cityi <br />gs�oa <br />C de <br />HOME or MAILING ADDRESS (If Dtfferent from Site Address) <br />3 Ca U nTLe—F SIC, Street Number <br />Street Nam <br />CITYSTATE <br />Sf0C- t0� <br />zip <br />CCx- <br />PHONE #1 ExT• <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rJ XIS 7 t'n <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />HOME orMAILING ADDRESS <br />1 <br />�� <br />3Exr. <br />(AX# ) —3/ <br />CITY <br />-03 <br />• <br />STATE CA zip <br />Tsov <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 ENv[RoNmENTAL 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 appy 'on and at work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, and F la s. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ ERATOR / GER ❑ OTnER AUTHORIZED AGENT It —* ' e <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: U I -a d <br />rJ XIS 7 t'n <br />(J % I // S <br />L VC 5 <br />COMMENTS: <br />RECEIVED <br />MAR 2 1 2005 <br />5 <br />�f <br />O!� <br />kob61se <br />AQUIN COUNTY ` <br />I VIRONMENTAL <br />ACCEPTED BY: <br />J �t �, /. ,4. <br />EMPLOYEE #: <br />k',, ?� _ <br />F b&;rH DF—PAR_ <br />ASSIGNED TO: <br />�!- <br />EMPLOYEE #: <br />C 0✓2-2 <br />DATE: 3 Z I <br />Date Service Completed (d already completed): <br />SERVICE CODE: t7( <br />i E: <br />v <br />Amount: <br />- 11 <br />Amount Paid <br />Payment Date <br />(Os- <br />Payment Type <br />✓ <br />Invoice # <br />Check #(�� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />