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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />a� <br />�ep�4Ceitien�! O� 'FA✓�t� Sensu� Gt �'� <br />3 <br />67t-1-7 S:erre, o ort <br />1400&t5z0 <br />OWNER / OPERATOR <br />CITY0V �. rN <br />❑ <br />P -A rc <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Arco `-ISc> <br />ACCEPTED BY: O u L) 6— I <br />SITE ADDRESS 1 l_' ^7 <br />�'J . <br />I <br />f5�-eir cn 7 Street <br />ASSIGNED TO: VO lU lFLUJ9 <br />S toc.-KttO, <br />96-203 <br />Street Number <br />Direction <br />Street Name <br />Cfty <br />ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Amount Paid 13 16 011 <br />Payment Date <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />201) `Y62 • /617 <br />PHONE #T ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Inc. <br />COMMENTS: <br />PHONE # EXT. <br />S5- I.7SSS <br />HOME or MAILING ADDRESS <br />�ep�4Ceitien�! O� 'FA✓�t� Sensu� Gt �'� <br />FAX # <br />67t-1-7 S:erre, o ort <br />ilie- a" <br />Ns-) SS"1. 7 P -?'F <br />CITY0V �. rN <br />STATE C`1. ZIP g11.5 f� <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 an FEDERAL laws. <br />APPLICANT'S SIGNATURE:- DATE: /6 <br />. -2S - 20 ! o <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Con + f -C, r t +C) r` <br />ffAPPLICANT 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: <br />COMMENTS: <br />A <br />rAY {V 1 EN <br />�ep�4Ceitien�! O� 'FA✓�t� Sensu� Gt �'� <br />#2 -E��I SvM�.dRE EiVED <br />7gy3 r0 - 3 r-1►-/ Vee-dG, 1�co t <br />OCT 2 7 201 <br />&QUIN COUt <br />ARONMENT <br />EPARTM <br />ACCEPTED BY: O u L) 6— I <br />EMPLOYEE #: <br />C,3-Z4DATE: <br />O r`�E <br />ASSIGNED TO: VO lU lFLUJ9 <br />EMPLOYEE #: <br />�3 17 <br />, <br />DATE: t� 27 r V <br />Date Service Completed (if already completed): <br />SERVICE CODE: ! <br />PIE: 1-301? <br />Fee Amount: S 3G 6 pD <br />Amount Paid 13 16 011 <br />Payment Date <br />Payment Type(2W:,i CJz� <br />Invoice # <br />Check # <br />Received By: M3 -- <br />CAD,, -it A N-7 $ 79 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />IN <br />NT <br />