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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS Mr <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE# EXT. <br />EMPLOYEE #: �� 1 <br />(/ <br />DATE: -7h NO <br />0�1 �1/V( <br />OWNER/ OPERATOR <br />DATE: ZU <br />CHECK if BILLING ADDRESS <br />P —t t <---2 <br />SERVICE CODE: <br />P / : <br />V <br />FACILITONAME , <br />"S-TAFzip Gjj �^ <br />006 <br />Payment Date <br />Payment Type / ��"' <br />Invoice # <br />SITE ADDRESS <br />Received By: <br />�j I <br />� <br />�t elftame <br />3 <br />Street Number <br />ire�o <br />`� <br />HOME or MAILING ADDRESS (If Different from Site A dress) <br />o 90 S <br />� S <br />Street Number <br />Street Name <br />CITY <br />STAT zip <br />��Gc'✓l <br />�- <br />/ l J Z <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />(yz,T) 7,0, s 70 7 7 <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORR <br />CHECK If BILLING ADDRESS Mr <br />BUSINESS NA / <br />'SAN <br />dogQU� <br />H&T�/RONM, outs <br />yoZp� MENr <br />PHONE# EXT. <br />EMPLOYEE #: �� 1 <br />(/ <br />DATE: -7h NO <br />S -per77 <br />HOME or MAILING ADDRESS <br />DATE: ZU <br />FAX # <br />SERVICE CODE: <br />P / : <br />V <br />CITY C L / <br />"S-TAFzip Gjj �^ <br />006 <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: 71712c) ZO <br />PROPERTY/ BUSINESS OWNER O TOR TANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPL/CA is n e B/CLING PARTY proof of authorization to sign is required Tire <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, PAvA._ <br />TYPE OF SERVICE REQUESTED: �/� (� <br />%� S n FC r <br />COMMENTS: <br />'SAN <br />dogQU� <br />H&T�/RONM, outs <br />yoZp� MENr <br />ACCEPTED BY: LA 66-1 S , <br />EMPLOYEE #: �� 1 <br />(/ <br />DATE: -7h NO <br />ASSIGNED TO: a ri ( <br />EMPLOYEE #: 33Cp/ <br />DATE: ZU <br />Date Service Completed (If already Completed): <br />SERVICE CODE: <br />P / : <br />V <br />Fee Amount: 2 �V <br />Amount Paid <br />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 />