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SAN JOAQ COUNTY ENVIRONMENTAL HEAL'; APARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID #p <br />SERVICE REQUEST # <br />bs- <br />OWNER/ OPERATOR1 �'``&G� ' `�T MA�' ON <br />W CHECK ifBILLIN ADDRESS <br />V <br />FACILITY NAME �( � (`LAG & (� / r ts7MtQZINA <br />HOME or MAILING ADDRESS <br />s o <br />SITE ADDRESS <br />60 60, 5/9 Street Number <br />Direction <br />C <br />G D <br />�treet Nam <br />sZO (Z(<NT0 <br />cityZi <br />RECEIVED <br />ci SQ r 9 <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />SAN JOAQUPN COUN7Y <br />PHONE #1 ExT.APN <br />909) 95 (- (5si <br /># <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORC.r (^ rn 1�� J <br />�{ }1 [v <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME �M ^ ,u <br />PHONE# 6:2�7_ <br />HOME or MAILING ADDRESS <br />s o <br />F# <br />A01) 537- 9 3018 <br />CITY C�.c�{F,S <br />STATE ZIP 4 5307 <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 <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 <br />__and <br />((FEDERAL laws. D }� <br />APPLICANT'S SIGNATURE: DATE: C. t.�/� , �' DATE: 9 -a 7- <br />PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTIIER AUTIIORIZED 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 />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />SEP 2 7 2012 <br />SAN JOAQUPN COUN7Y <br />ENV;RONMENTAL <br />HEALTH DEPAR <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />��1 Ej� <br />Paymeift <br />Date .� Z <br />Payment Type <br />Invoice # <br />Check # <br />O� <br />Received <br />�(, — <br />EHD 48-02-025 SR FORM (Golden) <br />REVISED 11/17/2003 <br />`v <br />