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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Z SERVICE REQUEST A -9 - <br />Type of Business or Property FACILI # 3L loY CE REQUES <br />OWNER / OPERATOR \/ <br />CHECK if BILLING ADDRESS <br />FACILITY NAM 57 <br />Dr <br />SITE DRESS / �, �/ �rT ��/j <br />c---7,4 <br />Street Number Direction (�-Zel „1 ,Street <br />CiZi C e <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />CITY Street Number Street Name <br />STATE <br />PHONE #1 EXT. APN # LAND USE APPLICA E IVE D <br />( ) <br />PHONE#2 EXT. BOS DI RI T LOCA ON CODE 1 06 2015 <br />( ) <br />REQUESTORCONTRACTOR / SERVI RE U TOR ENVIRONMENTAL HEALTH <br />� ` , T/SERVICES <br />CHECK if BILLING ADDRESS <br />BUSINESS FLAME A PHON <br />HOME O MAILING AD RESS `/'/� P¢✓ Y <br />/y <br />Lt77 <br />�-3'IJ <br />FAx # <br />) � <br />STATE Zip <br />BILLING ACKNOWLEDGEMENT: I, the undersigned pr perry or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENv1RONM TAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed tome or my business as identifie on this form. <br />I also certify that I have prepared this application and at t work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F ERAL ws. <br />R—� <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY /BUSINESS OWNER OPERA OR/ MANAGER ❑ OTHERAUT ENT ❑ pA� 0 <br />IfAPPLICAN is not the BIL NG PARn' proof of authoriza ' equired Title R wE <br />AUTHORIZATION TO RELEASE 'FORMATION: When l a he owner or operator of the prop the ►� 2015 <br />above site address, hereby author the release of anan s <br />Y ,eot�eo ] data and/or e ble.o ss�enPQu Mew <br />information to the SAN JOAQUIN C TY ENVIRONMENTAL HE DEP I <br />z� s soon as s availablQ t same tan�s�� <br />provided to me or my representat e. � P'l �P�� � � � � <br />TYPE OF SERVICE REQUESTED: M�N AV�Cj <br />COMMENTS: - <br />1 A Al V <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): i <br />Fee Amount: �j 3 p , p -C) Amount Paid <br />Payment Type L,,-' Invoice ## (ot�Se <br />EHD <br />REVISEDSED 11/1 11/17/2003 <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />3 1?c7, p Payment Date <br />Check # n <br />DATE: <br />DATES^��/�//� <br />P/E: �3 <br />Received By: <br />SR FORM (Golden Rod) <br />J <br />00 -9 <br />