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W, <br />SAN JOAQU*OUNTY ENVIRONMENTAL HEALT19PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />o Ct n, L 1 <br />S -2- <br />DATE: /_ Z r-0 <br />Y' <br />OWNER / OPERATOR <br />OWNER <br />EMPLOYEE #: 1 C Z� <br />30 <br />Date Service Completed (if already completed): <br />CHECK If BILLING ADDRESS <br />e <br />P 1 E: 3 �� <br />FACILITY NAME � <br />Amount Paid -V3 LfS v o <br />Payment Date <br />SITE ADDRESS -11-7 <br />U� � <br />8� <br />ST <br />Check # "7 <br />S4D�/ � -t <br />()„5 20 (o <br />Street Numl»r <br />Direction <br />treat Name <br />city`i-Zi� <br />Coda <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT•APN <br />Ycc -lolot�-000 <br /># <br />/03--too.-�� <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />BOS DISTRICT � <br />LOCATION CODE <br />coS) 9 _ U (a <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /, n t -� % � '} <br />t/ CHECK If BILLING ADDRESS <br />BUSINESS NAME l / •� �� J v TrAe . PHONE # �D — EXT <br />HOME or MAILING ADDRESSr G FAX# <br />( S ra rtoe.c M. 1 (20() Rq5-F9s3 <br />CITY Irk, (/Aa IL STATE M , ZIP (%,S --A ( ( <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 appy 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws <br />/j / <br />APPLICANT'S SIGNATURE: / o /JCS -,-1 Lc Qom`- DATE: (2112-010� / <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 9 uchA—h—n� <br />If APPLICANT 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. !,, (_ S 7 1 AJ,C 1V -,D- F i ! <br />TYPE OF SERVICE REQUESTED: V I— <br />COMMENTS:� / (� n /y h �GYL�1� /5,� L '/( �U�� ec PC/"q <br />fes/ Tc�V'/`' �/�S� Plot v1wC/ L x`'1.0 .i-+"tv G� <br />a -. U e ecu"b <br />�t <br />toZL`( Save WevobwS �1«�.ti� �ISiLv� b.e'Cc)('e S4t4elou, <br />ACCEPTED BY: L( L) l li° T <br />EMPLOYEE M C3-2_ • <br />DATE: /_ Z r-0 <br />Y' <br />ASSIGNED TO: <br />EMPLOYEE #: 1 C Z� <br />DATE: <br />2t f -0 <br />Date Service Completed (if already completed): <br />SERVICE CODE: I t� <br />P 1 E: 3 �� <br />Fee Amount: <br />Amount Paid -V3 LfS v o <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # "7 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />PAYMt_nI I <br />RECEIVED SR FORM (Golden Rod) <br />Jul, 2 1 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />,,,,L,n1 DEPARTMENT <br />