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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRE$ <br />FACILITY ID # <br />SERVICE REQUEST # <br />Rcasta <br />-tP <br />(�GSSII'��C2 <br />sRoo 7S-bq3 <br />OWNER / OPERATOR /^1 n`M <br />' <br />CHECK If BILLING ADDRESS <br />FAciurY NAME O �1✓b� <br />pop ,F O�N)Y <br />P \ LZ A <br />SITE ADDRESS <br />�F'YT <br />ACCEPTED BY: <br />�tI/'�'\� fy'� <br />/\-� <br />DATE: _ / p' <br />Str�Number <br />Direction <br />EMPLOYEE #; <br />DATE: e»?_ /t� <br />Date Service Completed (if already completed): <br />HOME or MAILING ADDRESS (If DIHerent tram Site Address) <br />Street Number <br />PIE: � 6 J <br />CITY ^ <br />Amount Pai <br />STATE zip <br />Co <br />PHONE #t ET, <br />(DOA)313-` <br />`) X <br />APN # LAND USE APPLICATION # <br />PHO6E )2 6 _� / Q Exr. <br />d (O <br />BOS DISTRICT <br />6 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �ACLn <br />CHECK If BILLING ADDRE$ <br />BUSINESS NAMEP <br />Ch1! <br />'' X10 l 2 Z 11 <br />N #^ ExT <br />7 --7q YU <br />HOME or MAILING ADDRESS Z <br />(�GSSII'��C2 <br />FAx# <br />CITY 1 0 1CTON \ <br />STATE 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 or <br />activity will be billed to me or my business as identifl d on this form. <br />also certify that I have prepared this app' 'on n that thew dk to be onned will be done in accordance Wth all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA EDE L la <br />APPLICANT'S SIGNATURE: DATE: o� D <br />PROPERTY/ BUSINESS OWNER OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT ❑ <br />UAPPLICANT is not the BILLING PART proof of authorization to Sir is required Tide <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessjbgtinformation <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Ear time It I rme Or <br />my representative. <br />FOft <br />ns. Fti, <br />TYPE OF SERVICE REQUESTED: Po -o c/ pkv? <br />Fc <br />COMMENTS: <br />✓O <br />CIO, <br />O, <br />yFq <br />h <br />pop ,F O�N)Y <br />�F'YT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: _ / p' <br />ASSIGNED TO: <br />EMPLOYEE #; <br />DATE: e»?_ /t� <br />Date Service Completed (if already completed): <br />SERVICE CODE: Z <br />PIE: � 6 J <br />Fee Amount: d <br />Amount Pai <br />L{SG b D <br />Payment Date <br />`) X <br />Payment Type �J <br />Invoice # <br />Check # <br />Rece{ved By: <br />EHD 48-02.025 <br />07/17/08 (� g053l�] SR FORM (Golden Rod) <br />{1/ 11 �_ <br />