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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />APLtJ III�tl'fs <br />BUSINESS NAME (� /� <br />Durk 5 1'(Jv( Ius <br />FACILITY ID <br />J <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CrrY , pull <br />ul,l STATE / L ZIP C/ 5 C, <br />CHECK K BILUNG AOORE88 <br />FACILrrt' NAME nn 1 <br />�rlF�w�oc ITQt+rTMP'i �S <br />ASSIGNED TO: <br />SITEADDRESS <br />t✓ J Street Number <br />�J <br />I Dire 11on <br />Date Service Completed (if already completed): <br />/ �R�1 'fie �� <br />v 1' 8 Nana <br />SERVICE CODE: <br />f/'4C )• <br />C1W <br />yj3�.� <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />elnal Number <br />Amount Paid <br />Street Neme <br />CITY <br />STATE ZIP <br />PHDNE#1 <br />( 1 <br />APN Ii <br />LAND USE APPLICATION# <br />PHONE#2 Exr. <br />( ) <br />BOS DISTRICT <br />11 <br />LOCATION CODF <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Ef lt� n /i'1 sure CHECK If BILLING ADDRESS <br />BUSINESS NAME (� /� <br />Durk 5 1'(Jv( Ius <br />�r`�f <br />P"=N# 5Y9-3)1 <br />HOME Gr MAILING ADDRESSn �� <br />( C -j /(/, I-rnu4 It � <br />FAX ) <br />CrrY , pull <br />ul,l STATE / L ZIP C/ 5 C, <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 FED laws. <br />APPLICANT'S SIGNATURE: DATE: (i L� <br />PROPERTY/ BDsavEss OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT D, -q rl S Mf n <br />1fAPPLLCANT tS not theBwArGPARTY /roof of authorization to sign is required Title <br />AUTHORIZATION T_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 JOAQUIa 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 />Fee Amount: <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 11117/2003 <br />