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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 110R.<E RID N c/sir 52ool 41" <br /> OWNER I OPERATOR <br /> m N CHECK If BILLING ADDRESS <br /> ,*IS- -7E NiN6 � <br /> FACILITY NAME <br /> b2 NON-SRO 5S/STANi-6 LLG <br /> SITEADDRESSoZ��OV E �e,4,np0 ROAD CLEi7ENT$ %5�.�7 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAULING ADDRESS (If Different from Site Address) <br /> SAM E Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION IT <br /> (acyl 7¢'- ZS{G a 3 - 1290-/S IA- 1100 13 <br /> PHONE#2 ExT. BIDS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> O �C-/ Ye5NE CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> t ECON al- /N -/ 03 <br /> HOME or MAILING ADDRESS FAx If <br /> P o - BOK 37q4 ( ) &0-25 k <br /> CITY ` STATE C A <br /> ZIP /S�3 <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 appli ion and that[t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S YTVand FERE. nWS. <br /> APPLICANT'S SIGNATURE: DATE: A <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NI NAGER ❑ 13/.' HER AUTHORIZED AGENT Y] <br /> 1fAPPL/CANT is nol the BILLING PARTY proof of auth zation 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: (,/QG!/ O WA f /AA/ CpkymENT <br /> COMMENTS: , I I I <br /> RECEIVED <br /> /' � �t� 2c✓/ JAN 18 2012 <br /> C f x-t---Xe <br /> / SANMENNTTAI. <br /> EIMRON <br /> (CFO,'r•:✓ HEALTH DEPAaTYIDrr <br /> ACCEPTED BY: 1 r, EMPLOYEE#: 17 <br /> O / DATE: <br /> ASSIGNED TO: 5 cc)Tz�' EMPLOYEE#: t I g1L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZ Z -FF/E' 2-L?/ <br /> Fee Amount: .S V C, Amount Paid Payment Date . <br /> Payment Type �; Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />