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SERVICE REQUEST <br />Type of Business or Property <br />G r Z .3 r5 'Stc-r!��i -t- <br />I <br />FACILITY ID # <br />BUSINESS NAME <br />4A -+--j <br />SERVICE REQUEST # <br />I <br />OWNER I OPERATOR <br />U 411 1 F1 4F 't.0 r ki <br />EXT. <br />CHECK if BILLING ADDRESS 0 <br />FAciuTy NAME L) <br />FAx # <br />( <br />) '5 '76 2- <br />SITE ADDRESS <br />1 sq C) S' et Number <br />I Di tion <br />C CIO qMm <br />Name <br />Invoice # <br />F <br />03 Z 15 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Sh*0 Number <br />T <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #1 Exr.APN <br /># <br />LAND USE AppucATioN # <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />CHECK if ENLUNG ADDRESSIQk <br />BUSINESS NAME <br />4A -+--j <br />DATE: <br />PHONE # <br />(%I) <br />EXT. <br />HomLor WuNG ADDRESS <br />V <br />Date Service Completed (If already completed): <br />FAx # <br />( <br />) '5 '76 2- <br />CITY V 4 rs I ap- <br />STATE <br />7jp <br />q <br />BILLING ACIQOWLEDGEMENT: 1, 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, STA ft and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ot DATE: <br />PROPERTY / BustNEss OWNER 13 OPERATOR/ MANAGER EJ O4AUTHORIZED AGENT 1%--Pr.:i.S �- <br />IfAPPLicANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount <br />I Amount Paid <br />I Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />