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0 0 <br />SAN JOAQtAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQ, I rc-r <br />Type Of Business or Property <br />g * . <br />FACILITY NAME <br />SITE ADDRESS <br />HOME or MAILING ADDRESS <br />CITY Street Number <br />STATE <br />?'HONE 91 EXT. <br />Al"N 9 <br />LAND USE <br />PHONE #2 <br />EXT <br />BOS DIST <br />CONTRACTOR1 SERVICERE <br />CILIQUES <br />REESTOR ILQUES <br />BusINEss NAME <br />I <br />■ <br />#Z <br />ip <br />PLIC 'ION <br />r <br />LOCATION CODE <br />R <br />- Jl_-1 <br />C <br />FAX # <br />f';ITY( <br />STATE ZI <br />T: I. the tindersigl)cd property or husin P I�ge>t <br />aci%110%viedge that all site arid or project specil-ic ss oisner. operator or 3111horized of same, <br />%1I'k I hourly charges associated with this project <br />or activity will be billed to me or in <br />Y ht'siness as identified on [his forl"ll. <br />I also certik that I ha\e prepqrcd 111, <br />C(w \ IN, o1"c1it1WW,1 ( o( is application and that tile \wrk to be 1) - I <br />le' S I A I I and ['I of 1�,\l o"lle(l " ill be (1011c ill accordance kith all SAN JOA(�)l IN <br />A P P t. I CA NVS S I (. N A'F( J7 R E: <br />PROPER -M <br />0 C 1 fit R kk I HoRl/t <br />lol the A" i of I' IR I, preiql'i?l alltlrr i iation to s iqll A requ ired J,. <br />AU'rijogiz-A-FION 10 RELEASE IN'FORNIA'FION: When a ill �( <br />icable. I. the (mriter or operator ofille property located at the <br />above site address. liereby, ailthOrize (fie release of, ani d I results. <br />inforiiiation to the S -x\ if I,,\(), I\ I all 12cotcchnical data and or ell\ ironmental,' <br />provided to file or ill\ representative. <br />A Ull I I DI 1, \I, I, site assessment <br />entati% e. as "')of' as it is a�,Illahle and at the same time it is <br />TYPE OF SERVICE REQUESTED: <br />ACCEPTED BY:■ <br />AssIGNED TO: <br />Date Service Completed (if already comPleted): <br />Fee Amount: <br />Amount Paif <br />Payment fype <br />EHD 48-02-025 <br />REVISED 11!1 712003 <br />1 EMPLOYEE*: -T--- <br />DATE: <br />EMPLOYEE #: DATE: <br />SERVICE CODE: P / E: <br />Payment Date <br />Check # <br />Received By: <br />SR FORM (Golden Rod) <br />