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SANJOAQuixouwy ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property /'Q FACILITY ID# SERVICE REQUEST# <br /> -mI4,e � Dui S W Ou D- <br /> ONER/0PERAT0 <br /> CHECK If BILLING ADDRESS <br /> V Q ST <br /> FACT Y % 44�3 �y <br /> SITE ADD/,REBS �LG"�✓ <br /> V Street Number Direction Street Name C Zi Code <br /> HOME Oj)MAIILI e3 ADDRESS (if 'f erent)f�rom Site Address) a <br /> /l..-�'l ,e axA ,9 � Street Number Street Name <br /> CITY ��i� STATE ZIP7,A -7 <br /> v/� <br /> 04 <br /> PHONE#1 E". APN# LAND USE APPLICATION# <br /> ( `] ) 2,51, 3 02 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R,EQUESTQR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"T' <br /> (16 ) 3 -qIfy/ <br /> HE r ILINGADDRES FAX# <br /> TT (f 7 013 ) 3S-1-1',51 <br /> C!r()J �J }� STATE ZIP 6-1�,J <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property of business owner, operator or authorized agent of same. <br /> ackno\\ledge that all site and/or prc�iect specific ENI-IRO NNIENTAL HE_aLT11 DEP.\RT1\fWF ho uriv charges associated with this project <br /> or activ-itv will be billed to me or mv-business as identified on this form. <br /> I also certify that I have prepared this app is tion and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEDERAL WS. <br /> APPLICANT'S SIGNATURE: /. DATE: y- <br /> PROPFRTI/BITSINE'.4Q\\NER❑ C)FERaT(.)R/ \LaN.\G OTIIER.�LTHORIZFS)at ENT <br /> If•1PPLIC:d�7 is n.�tJIIeBILL1.\t:%P.-1KT1,proo_/•of[Jurlrori.,uriorr to sin is regrtirerl! � Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable.I. the owner or operator of tlIpATtVs, <br /> N�tteil at the <br /> abo\e site address. hereb\ authorize the release of an\- and all results. gei,teclmical data and/or en\imEyessment <br /> info rnmtiin)to the SAN JOA*QUIN COUNTY ENVIRO Ni\fENTAL HEALTH DEP_-\RTNMNT as Soon as it is a\ailablef'altlme time it is <br /> provided to me or m\ representative. 1 <br /> TYPE OF SERVICE REQUESTED: DIST uru <br /> COMMENTS: /AN rJu A7 <br /> 2ASHL N "`�r <br /> �4 IC411Q, W6)6 6y,1U a� -71-11 C / 15 <br /> ACCEPTED BY: EMPLOYEE#: t�L DATE: <br /> ASSIGNED TO: ` EMPLOYEE#: Fffu q DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: j /, P 1 E: a g' <br /> EeeAount: C Amount PaidPaymentDate <br /> t Type V11 Invoice# Check# / D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />