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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />7 <br />FACILITY ID # <br />SERVICE REQUEST # <br />c,-"s^o P c -f� <br />En <br />BUSINESS NAME <br />_—�— <br />PHONE # <br />OWNER / OPERATOR 1/ 7�11� <br />"- w-- G r n L <br />•Tre') o CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: <br />FAX # v Op <br />SITE ADDRESS I � 4 A <br />P / E: <br />E aS -r /\/")u I <br />(,clA <br />s --t�� +U✓� <br />s is <br />Stree Number <br />Direction <br />Invoice # <br />Street Name <br />Received By <br />c1tv <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />-70 <br />EXT. <br />APN # <br />33 <br />LAND USE APPLICATION # <br />( ��)Ll <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />7 <br />CHECK If BILLING ADDRESS <br />e <br />S � <br />En <br />BUSINESS NAME <br />_—�— <br />PHONE # <br />DATE: <br />ASSIGNED TO: klt S <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX # v Op <br />SERVICE CODE: Cy _ <br />P / E: <br />CITY <br />STATE ZIP D rn C') <br />Amount Paid 1570'1, <br />� Z O_ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent ijis e,p0 <br />acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this WJe or <br />activity will be billed to me or my business as identified on this form. <br />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: �^v�L�-� J `�— DATE: lTl 2 c ) <br />PROPERTY/ BUSINESS OWNER Er OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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 assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is provided t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />7 <br />COMMENTS: TO V ` I <br />e <br />S � <br />` jo Vv &' <br />S.�e�✓l <br />ACCEPTED BY., - <br />_—�— <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: klt S <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Cy _ <br />P / E: <br />Fee Amount: t 5'��O <br />Amount Paid 1570'1, <br />Payment Date I �� <br />Payment Type C-l-�f— <br />Invoice # <br />Check # a LV S' <br />Received By <br />M <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />M a <br />jnZ <br />v-4- <br />