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NAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTAIENT <br />SERVICE REQUEST <br />Typ 2 Of Business or Property <br />�^� <br />n FACILITY ID # <br />v00 2— <br />SERVICE REQUEST # <br />OWNER/ OPERAT <br />OWNER/ <br />CHECK if BILLING ADDRESS <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />SITE ADDRESS `� 1'11 f <br />Street Number Direction <br />�11, <br />p �t Q <br />Ci `" _ ` Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />HOMEOrMAILING ADDRESS �0')j� \O � <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #'I <br />( ) <br />ZIP <br />APN # <br />LAND USE APPLICATION # <br />PHONE #T EXT <br />( ) <br />`✓ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />. \� / ' PAYMENT <br />RECEIVED <br />`C ` <br />i j�_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />L\a <br />) <br />- <br />HOMEOrMAILING ADDRESS �0')j� \O � <br />F�) <br />`; r7 �D, <br />CITY r <br />STATE <br />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 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, St ds, STATE and FEDERAL aws. <br />APPLICANT'S SIGNATURE: <QSL l�,y,{� ,�Z DATE: <br />PROPERTY/ BUSINESS OWNER ❑ 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, 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 environmental/site assessment <br />information to 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 />n <br />TYPE OF SERVICE REQUESTED: <br />. \� / ' PAYMENT <br />RECEIVED <br />COMMENTS: <br />MAR 2 2011 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />`✓ <br />EMPLOYEE #: Oleile <br />DATE: � / <br />ASSIGNED TO: <br />' <br />EMPLOYEE #: Z <br />DATE: / <br />Date Service Completed if already completed): <br />SERVICE CODE: C? <br />1E,Z-:s of <br />Fee Amount: <br />G ""' <br />Amount Paid -1�3LL r 0-(0 <br />Payment Date 3 <br />Payment Type <br />✓ <br />Invoice # <br />Check # (o3�s <br />Received By: <br />EHD 48-02-025 }SR FARM (Golden Roil) ` <br />REVISED 11/17/2003 <br />