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SAN JOAQ4 COUNTY ENVIRONMENTAL HEALTf EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # 11 SERVICE REQUEST # <br />•o - <br />A / <br />a I SRe� <br />OWN RI OPERATOR <br />BUSINESSNAM <br />•t A Q 2, <br />EXT. <br />CHECK IT BILLING ADDREsa11 <br />FACIDTY NAME <br />e ro H <br />ts-)T <br />Wa- <br />SITEADDRE55 <br />jp�' <br />FAX# <br />tree Re <br />L,,/�t�)= <br />], 59—L 0 <br />I'``'/LLZI <br />u her <br />meelo <br />CITY <br />aL-V) <br />ZIP q5 (-e3 -2- <br />Cll <br />Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P1 E: ' <br />Fee Amount: 'S W <br />Amount Pald <br />Street Number <br />Seeet Neme <br />CITY <br />Payment Type <br />STATE ZIP <br />PHONE#1 ExT. <br />APN# <br />Received By: <br />LAND USE APPUCAT10N8 <br />PHONE#2 En. <br />t ) <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQVESTO <br />- <br />COMMENTS: <br />CHECK If BILLING AODRESa� <br />BUSINESSNAM <br />PH E# <br />EXT. <br />n N JOAQUIN Coe <br />ENVIRONMENTAL <br />W ^, <br />— OV✓� <br />HOME Or MAILING ADDIJEiS <br />11 ALTH DEPARTME <br />FAX# <br />EMPLOYEEM <br />yi 3 <br />DATE: -2 <br />I <br />ASSIGNED TO: (ti, <br />CITY <br />STATE <br />l: -a- <br />ZIP q5 (-e3 -2- <br />BILLING <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 prepaz tl- plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, andards, TATA and ERAL <br />APPLICANT'S SIGNAT RE: v DATE: 2 L <br />PROPERTY/BUSINESS OWNER ERATOR/MANAGER ❑ OTtURAOTuoruz DAGENT ❑ <br />IfAPPLfCANTisnolthe BtLLwGPARTY 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saptAftit' <br />provided to me or my representative. RECEIVED1 <br />TYPE OF SERVICE REQUESTED: <br />- <br />COMMENTS: <br />n N JOAQUIN Coe <br />ENVIRONMENTAL <br />11 ALTH DEPARTME <br />ACCEPTED BY: <br />EMPLOYEEM <br />yi 3 <br />DATE: -2 <br />22- <br />ASSIGNED TO: (ti, <br />EMPLOYEE <br />Cj' `�� <br />DATE; <br />Date Service Completed (if already completed): <br />SERVICE CGDE:, E2-2, <br />P1 E: ' <br />Fee Amount: 'S W <br />Amount Pald <br />J <br />Payment Date <br />a,o aZ <br />Payment Type <br />Invoice # <br />C # <br />Received By: <br />EHD 40-02-025 I tSR FORM Golden Rod <br />REVISED 11/17/2003 J C'erP+c1,J L -Ll ��tih'� I3 pJ 4 001'5 ( ) <br />q <br />