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CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />SAN JOAQUIN' OUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />0 <br />BUSINESS NAME ,. <br />U <br />` i n <br />SERVICE <br />REQUEST <br />Qc_1) '--16 l b 7`i 2 <br />CITY STATE ZIP <br />Type of Business or Property <br />FACILITY ID # <br />fA <br />SERVICE REQUEST # <br />( <br />OWNER / OPERATOR <br />C <br />DATE: <br />CHECK If BILLING ADDRESS <br />©r <br />� � � <br />Fee Amount: <br />),),-7Amount <br />FACILITY NAME <br />L <br />�fl 0l) <br />Payment Date 9 zo cI5 <br />Payment Type <br />SITE ADDRESS <br />1J -)s <br />I <br />t^0. C <br />Q i u cc\ <br />l <br />Street Number <br />Direction <br />Street Name <br />ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�1 <br />1 <br />1(� �) �3 r °� P C, <br />Street Number <br />Street Name <br />CITY � \ �- <br />` <br />STATE � � ZIP <br />0 <br />ExT• <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />2o) S 3 5" - s3� <br />ikh <br />PHONE #2 ExT. <br />BOS DISTRICT 71 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />PA`tMttED <br />BUSINESS NAME ,. <br />U <br />` i n <br />PHONE# EXT' <br />( 0 y - 33 <br />HOME Or MAILING ADDRESS <br />Qc_1) '--16 l b 7`i 2 <br />CITY STATE 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, Stand rds, STATE and FEDERAL laws. /� <br />APPLICANT'S SIGNATURE: Q,� DATE: Q- .0 C" " <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �I S <br />If APPLICANT no 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: G <br />PA`tMttED <br />COMMENTS: <br />O 2005 <br />StP 2 <br />SAN JOAC IUIN COUt4T`! <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />OL[ Li`C t <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />( <br />EMPLOYEE M © <br />DATE: <br />Date Service Completed (if alrev4 completed): <br />SERVICE CODE: ( <br />P 1 E: <br />Fee Amount: <br />),),-7Amount <br />Paid <br />�fl 0l) <br />Payment Date 9 zo cI5 <br />Payment Type <br />V,, <br />Invoice # <br />Check # , b 3 <br />Received By: N L (s <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />