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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CRsf,NI�: G'OERAT�O►�( Bu5f)(E55 I <br /> OWNER I OPERATOR <br /> i YI2 /CE/7-1-1 O G✓EL L CHECK If BILLING ADDRESS <br /> FACILfTY NAME <br /> /nE2I,4Atir (f,--?ANF RevTAZ- INS- /y� aa <br /> SITE ADDRESS !7800 S CO/i'ICd4,,5x /YJAn1T1=��1 /Sr336 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / <br /> /" . 6 . 80 3(/ Street Number Street Name <br /> CITY STATE G'A Zip 9S 3 7-62 <br /> �SC,r_( LOnf <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (ao9 ) el R — 53saz 962_ -a3 NOT /s5&6EC> yr <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (a01 ) 0 3 e - 57 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Do/'i CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> PROVOST PfZITCHAr:ZD CONf(,ILT/N( aoy 90 - a300 <br /> HOME or AILING ADDRESS FAX# <br /> -t70/ (.70 ) 809- �3 O <br /> CITY 1,�7OD ej TD STATE 11.^ ZIP /S 3 S-& <br /> BILLING ACKNOWLEDGEMENT: 1, 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 t on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S IJ and FED <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERT0 BUSINESS OWNER❑ OPERATOR/N ANAGER ❑ OT 'RAUTHORIZEDAGENT <br /> If APPLICA.hT is not Ilse BILL1A(;P.�IR7T proojojuuthori ation 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 ENVIRONMFNTAL 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: /V ITI¢o,TE LDA D/A16 Sviz. lw rTa 8i<zr STuO Rte✓/E <br /> COMMENTS' � PAYMENT <br /> 172 RFCF1VED <br /> JUL 2 3 2012 <br /> (� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: ��� EMPLOYEE#: ATE: <br /> ASSIGNED TO: -/t-5 1 C rPe1l.40S EMPLOYEE#: 4o DATE: _712—3 I Z <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 2-4e-C-1 Z <br /> Amount Paid Payment Date <br /> Fee Amount: �j�'` <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />