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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS IT <br />94a� o- <br />F�ICILITY ID # <br />^ <br />SERVICE REQUEST # <br />CV t''Q,J`i AM�J <br />uC <br />e 1 <br />HOME or MAILINGAyDRESSFAX <br /># <br />OWNER/ OPER R <br />7ju,NC V 4 94 eA1,n <br />ry <br />EMPLOYEE M 3 &/ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME' � 4ws1 <br />^ <br />SERVICE CODE:-/`!' <br />SITE ADDRESS cf 1 <br />/u, <br />m-o� Ile, �' 1 . <br />Amount Pai <br />�; WA%4 0 A <br />Date <br />_15 3 <br />Street Number <br />Direction <br />Street Name <br />Recei ed By: <br />CI <br />L Code <br />HOME orgMA�IUNG ADDRESS (If Different from <br />Site Address) <br />2 ti TStreet <br />Number <br />'1 Street Name <br />CIN J 1�CIL4())n <br />STATE 0-4 ZIP pT ZO3 <br />l <br />PHONE #1 Ev. <br />(Sin! 2D-4-166 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />'GY "°-` <br />7BUSINESSS <br />CHECK If BILLING ADDRESS IT <br />94a� o- <br />NAME <br />^ <br />PHONE # EXT. <br />ACCEPTED BY:EMPLOYEE <br />r%] <br />uC <br />e 1 <br />HOME or MAILINGAyDRESSFAX <br /># <br />ry <br />EMPLOYEE M 3 &/ <br />CITY �fi4 C ic+�Po <br />STATE ("4 ZIP <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 (formed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, _SF>' Mand FEDERAL laws. <br />APPLICANT'S <br />PROPERTY/ BUSINESS <br />DATE: <br />D OTHER AUTHORIZED AGENT ❑ <br />IfAPPL/CANT is not the & G -PAR proof of authorization to sign is required Tine <br />AUTHORIZATION TO RELEASE4NFORMATION: 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 salve time it Is <br />provided to me or my representative. Ab� <br />TYPE OF SERVICE REQUESTED: <br />R <br />COMMENTS: <br />JtYerr' 5moK2anc�lrtPa(bb$. iam <br />J <br />NOAQ�/9` �l <br />R <br />N��TH ON 'WNOIJN�, <br />ACCEPTED BY:EMPLOYEE <br />r%] <br />M <br />' <br />DATE: -711q19-1 <br />ASSIGNED TO: mj&rf <br />ry <br />EMPLOYEE M 3 &/ <br />DATE: -7 ' 2/ <br />Date Service Completed (if already completed): <br />SERVICE CODE:-/`!' <br />O <br />P I +W <br />Fee Amount: <br />Amount Pai <br />Payment <br />Date <br />Payment Type'A lkelxt <br />Invoice # <br />Check # `ZS <br />g <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />