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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Coiri5. .�(>. Compa) <br />CHECK If BILLING ADDRESS <br />FACILITY <br />A 0o� 1X130 <br />ID # <br />SERVICE REQUEST # <br />ov <br />� <br />OWNER / OP RATt%R��� r�'�Is��'c.�c���n <br />SqN JUS <br />CHECK If <br />BILLING ADDRESS Li <br />FACILITY NAME <br />? <br />CITY / / / <br />STATE zip \ CJOrQ <br />SITE ADDRESS <br />Z �SMIN 5 Street Number <br />L <br />e <br />` tree Na eve <br />city <br />ACCEPTED BY: +C�i���` lOr (C <br />ZIT) Code <br />HOME or MAILING ADDRESS <br />/(If DIVerent from Site Address) <br />Mc 0 /' c C. V IrI ✓l L a Street Number <br />EMPLOYEE #: 0 03 I <br />Street Name <br />ASSIGNED T0: (;a vvvo( F ton <br />CITY C4 l <br />[ <br />STATE n� ZIP <br />/ <br />PHONE #1 ExT• <br />(6/air 76 ( 36(a P> <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />Fee Amount: y I <br />BOS DISTRICT <br />S�. � <br />Payment Date <br />2� <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR / <br />Oin D �� /7� f G <br />G <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME W e 5 l V� 11 e `�`✓ <br />COMMENTS: <br />f4 -s•7^ <br />Exr. <br />PH N2ff 3666 <br />SqN JUS <br />HOME Or MAILING ADDRESS ^ <br />5 ry MC 6 llk?c L1 g' <br />FAx # <br />( ) <br />CITY / / / <br />STATE zip \ CJOrQ <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 />[ also certify that I have prepared this application <br />COUNTI' Ordinance Codes, Standards T�( <br />work to be performed will be done in accordance with all SAN JoAQuIN <br />APPLICAN'T'S SIGNATU}R�E: (/f/t/ (//' DATG: �� <br />PROPERTY/ uLISINESS OWNERLU OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of author/zatiou to sigh is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property <br />located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/oI• environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at fh same time it is <br />provided to me or my representative. _tj <br />lye <br />TYPE OF SERVICE REQUESTED: CE� S Pe v ee <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11!17/2003 <br />r <br />,,i <br />COMMENTS: <br />f4 -s•7^ <br />SqN JUS <br />t ✓Oq <br />f NEACTH <br />D Pq RN 4 L <br />TMFN <br />ACCEPTED BY: +C�i���` lOr (C <br />EMPLOYEE #: 0 03 I <br />DATE: 7/'s <br />ASSIGNED T0: (;a vvvo( F ton <br />C) <br />EMPLOYEE #: (J 3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERwcECODE: (, <br />PIE: <br />Fee Amount: y I <br />Amount Paid <br />S�. � <br />Payment Date <br />2� <br />Payment Type <br />Invoice # <br />Check # 2g74 �� <br />Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11!17/2003 <br />r <br />