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SAN JOAQUIT9 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business ornAProperty <br />FACILITY ID # <br />SERVICE REQUEST 11 <br /># <br />J0 <br />OWNER / OPERATOR �(�� t f-- �.� f—�� f� <br />C,V1/V 1W �/I <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />FAX # <br />SITE ADDRESS <br />2 -ms Street Number <br />I Direction <br />Street Name <br />t� j <br />ASSIGNED TO: R M 1 e 1' �� <br />J Ci <br />DATE: s/ 13 I ( 1 <br />Zi Code <br />HOME Or MAILING ADDRESS�f (if tDifferent nfrom <br />�1Site Address) <br />Street Number <br />"'" Street Name <br />P / E: b <br />CITY L ��?C \, ` <br />STAT ZIP <br />3 <br />PHONE#1 EXT. <br />(��► 4�2�' 32 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />( ) <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR N_��uc— <br />p—ccI (IW6 CHECK If BILLING ADDRESS <br />C <br />BUSINESS NAME <br />V ?, "OA <br />PHONE # ,, EXT. <br />HOME or MAILING ADDRESS ;M <br />FAX # <br />CITY L jt 1 \ ` ' J1Q <br />� <br />STATE /'f_ ZIP 7-30 <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 or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have preparedthis a ication and that the work to be rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE nd FEDERAL laws. I G <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER OP TOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as ent information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time IT III i Q,me Or <br />my representative. Rp^�.. j� <br />TYPE OF SERVICE REQUESTED: Pic- (ma n e n � C05 me.I ( <br />COMMENTS: L l'�', D ^ <br />SAN 2019 <br />JOAQU <br />4ONMEN UNn <br />AL <br />ACCEPTED BY:v <br />EMPLOYEE #: 9 g'3 <br />DATE: <br />t� j <br />ASSIGNED TO: R M 1 e 1' �� <br />EMPLOYEE #: 3 <br />DATE: s/ 13 I ( 1 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: LI (� <br />P / E: b <br />Fee Amount: I Sol <br />Amount P' Uv <br />S� <br />Payment Date <br />J� o A/ <br />Payment Type <br />Invoice # <br />Check # <br />Receided By: G, <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />