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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c,s Stcvcn - C Store 3&041 64 'g o 4"/9100 <br /> OWNER/OPERATOR <br /> C O CHECK If BILLING ADDRESS❑ <br /> Ge <br /> FACILITY NAME <br /> SITE ADDRESS ) W Ff•e f--I D/1 f S7ree t StOc 1 rc n �7SZ O 3 <br /> Street Number Dirwti n Street Name cityZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> QCt ) L162 . W-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> n O r Or-own CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> GIP - nInc— S SS1 - 755.5 <br /> HOME or MAILING ADDRESS FAX# <br /> 67H'7 S:Crrc, Ctflvt-t Su.'te 7- (91S) SS/- 7S8(Q <br /> CITY 0 lJ I �i STATE CG ZIP yys6F <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I J 1c, 20i <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER [3OTHER AUTHORIZED AGENT 10 J e ry, ,.t� <br /> Lc- I' /G/1 GW r <br /> IfAPPL/CANT 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: L1 S 'TSG/7 pAYM <br /> COMMENTS: Ppol�e_) �d,�l t� Sens©�• 2 � 2011 <br /> 1��T CJ JAN <br /> SAN JOAQVINEout4v <br /> ENV1 pEPAR�E� <br /> H�-TM <br /> ACCEPTED BY: L4 EMPLOYEE#: DATE: <br /> ASSIGNED TO: Ie, EMPLOYEE#: I Z, DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: 3G6 ©O Amount Paid 366. 0c) Payment Date , C11Z0„ <br /> Payment TypeCr o&+ Card I Invoice# Ohm” �AAS�C r C Received By: <br /> 71SI2 <br /> EHD 48-02-025 f1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />