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SAN JOAQUI .AUNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />f EQ �Lu,B <br />CHECK If BILLING ADDRESS Ir <br />FACILITY ID # <br />2� <br />AUG 14 2012 <br />SAN JOAQUIN COUNTY <br />ENIVIRONMENTAL <br />HEALTH DEPARTMENT <br />SERVICE REQUEST # <br />s <br />OWNER'i3OPERATOR - <br />./ <br />L I <br />/-CHECK If BILLING AD DRESSrG.I,- <br />FACILITY NAME - ./ 5'. <br />4 <br />PE. <br />N/ <br />`IJ <br />EMPLOYEE #: <br />DATE: <br />SITEADDRIEss- - <br />Sheet Number <br />Direct! <br />.krtn13 kCHDER® ��, <br />treat Name <br />PIE: Z <br />STo o <br />Amount Paid <br />gsLtq . <br />z Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Payment Type <br />Street Name <br />CITY <br />Received By: <br />STATE ZIP <br />PHONE#tEXT. <br />- <br />APN # <br />F82, 0 <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /,4 I E-: / Iqhe6/\ <br />CHECK If BILLING ADDRESS Ir <br />BUSINESS NAME I t t t I , I v , /y` / L // t <br />�1( 1 /`r'(— <br />AUG 14 2012 <br />SAN JOAQUIN COUNTY <br />ENIVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # ` O�T'� <br />HOME or MAILING ADDRESS Sr. <br />66 K 1 <br />EMPLOYEE #: <br />F # ) <br />16--05-46 <br />CITU '. <br />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 <br />or activity will be billed to me or my business as identified on this form. <br />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 a d FE ERA la /j7 <br />APPLICANT'S SIGNATURE:DATE: LY /D�r�,,�o� <br />PROPERTT/BI"SINESSOwSERD OPERATOR/ OTHER At THORIZED AGENT M�CUIU`�VpCTDlI <br />IfAPPLICA.vr is not the B1Ly\'G PARC y. 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: GIA./` <br />PAYMENT <br />COMMENTS: <br />P p��Q <br />AUG 14 2012 <br />SAN JOAQUIN COUNTY <br />ENIVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />Z <br />ASSIGNED TO: Z <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Z Z <br />PIE: Z <br />Fee Amount: b °` <br />Amount Paid <br />Payment Date 91 y /12 -- <br />Payment Type <br />Invoice # <br />Check # Z <br />Received By: <br />48-02- <br />REVVIISED 110!217/2003 ! ~ * "e) <br />SR FORM (Golden Rod) <br />"q 0r <br />