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i 'I JL <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST# <br />&V 77 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESSE] <br />FACILITY NAME <br />SITE ADDRESS ri <br />I.n LA <br />StoreQN. er tion Street <br />ch Zi Code <br />HOME Or MAILING ADDRESS (if Different from Site <br />Address) <br />'xreer Nam <br />CITY STATE zip <br />PHONE #) <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT. BOS DisTRICTODE <br />. CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR- E4J <br />ti <br />k CHECK if BILLING I _17Lr-r) _ADDRESS <br />A BUSINESS NAME <br />LA (P <br />HOME or MAILING ADDRESS # <br />t4 b <br />'CITY STATE <br />ZIP <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 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, Standards, STATE and FEDERAL lawk <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY/ 13USINESS OWNER❑ <br />OPERATOR/ MANAGER O. AGENT <br />IfAPPLICANT is not the BffLUNGPARIY proof of authorization to sign is required l— Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: JUJ <br />COMM <br />COMMEiTs: <br />PAY MEN <br />RECEIVED <br />AUG 1 1 2010 <br />SAN JOAQUINCOUNTY <br />ACCEPTED BY: f EMPLOYEE #: <br />0�924 <br />'ASSIGNED TO: CA- -r EMPLOYEE M2— <br />Date Service Completed (if already completed): <br />SERVICE CODE: / 9,:k <br />7 - <br />Fee Amount: 36t.clo Amount Paid '%3(oQ1[)_0 Payment Date <br />Payment Type Invoice # <br />L Check # <br />EHD 48-02-025 <br />REVISED 1111712003 <br />RTMENT <br />DATE: <br />DATE: <br />Hlill C) <br />PIE: <br />Z3 <br />( f f 0 <br />ReceivedtBv: ---,e <br />