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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rn <br />UI <br />Q V lltiit aytt <br />ABUSINESS <br />FACILITY ID # <br />NAME <br />�%tQ <br />SERVICE REQUEST # <br />PHONE# Ex. <br />'I C�- <br />"WC, <br />c0o� Z �, i <br />SQ L)o �-Iq <br />OWNER 1AERATORA/,{'/, <br />CtU <br />(CtV1C <br />CHECK If BILLING ADDRESS <br />' `t/t a <br />t• <br />STATE 4 ZIP !a5 r1 Q <br />FACILITY NAME <br />, W QUIN <br />y� J;'?0 <br />SITEAODRESS <br />ACCEPTED BY:t,,(es <br />V. J <br />II G�✓1n `r` �� <br />EMPLOYEE#: <br />Q 1 �h <br />��jZa �j <br />Street Number <br />Direction <br />CtlSt-re t eme <br />JCt� .'�T I <br />ZI Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: 06-1 <br />/ZV <br />UJ <br />u iT <br />Street Number <br />Amount Paid <br />Street Name <br />CITY 5k 1\ CGh <br />Payment Type <br />STATE ZIP CI'D <br />PHONE#1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />(2oq) 64u 8660 <br />PHONE#Z <br />En. <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rn <br />UI <br />Q V lltiit aytt <br />ABUSINESS <br />CHECK if BILLING ADDRESS <br />NAME <br />�%tQ <br />COMMENTS: <br />PHONE# Ex. <br />bvu uY <br />"WC, <br />( zoq I 6`64 4 666 <br />HOME Or MAILING ADD ESS <br />FAX # <br />S 1 e... It '� <br />( , <br />CITY C I <br />STATE 4 ZIP !a5 r1 Q <br />BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: �lct CiIVAdIIJUA11 t SOw�eL � DATE: <br />/ PROPERTY / BUSINESS OWNE42 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PAR Trproof ofauthorization tosign isrequired 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 t0 the SAN JOAQUIN 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 />W <br />,` S U <br />�'l 4 <br />COMMENTS: <br />"WC, <br />�4c'y <br />$F0 31�? <br />, W QUIN <br />y� J;'?0 <br />FNTUN)Y <br />ACCEPTED BY:t,,(es <br />V. J <br />EMPLOYEE#: <br />DATE: �- —�Z <br />ASSIGNED TO: <br />CSIfAi/ L� <br />EMPLOYEE#: <br />DATE: -.- l,3 <br />/1 <br />Date Service Completed <br />(if already completed): <br />y <br />SERVICE CODE: 06-1 <br />P 1 E: G y? <br />6v <br />Fee Amount: <br />(;2— — <br />Amount Paid <br />15a.— <br />Payment Date �3 2Z <br />Payment Type <br />Invoice # <br />Check # <br />Received By: UV71r <br />EHD 4ygh "V SR FORM (Golden Rod) <br />REVISEDED 11/1 11/17/2003 v <br />