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-- <br /> 11/12/2020 11:2' AM PST <br /> SRN JOROUCN COUNTY EIJVIRONMENTRL HEALTH kQ�COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> [868 E. HAILI`LTON AVE, SERVICE REQUEST <br /> srMoN, CR 95205 FACILITY ID# SERVICE REQUEST# <br /> S /2_q ri <br /> TERNINRL WE: 18650401 aa 67- 0 V <br /> a M. CHECK if BILLING ADDRESS <br /> ORDER h: IS 96013 <br /> PAYMENT N Cord Road Clements 95227 <br /> Street Name City 2i Code <br /> SERVICE REOUEST OR WELL PE•,. $304.00 It from site Address) <br /> 82878 Street Number Street Name <br /> 0 0 STATE zip <br /> CA 95227-0279 <br /> AGENCY SUBTOTAL: $304,00 <br /> APN# LAND USE APPLICATION# <br /> LEXISNEXIS SERVICE FEE: $6.96 <br /> 1023-200-050 <br /> TOTAL USD: $310.96 Exr 11 BOS DISTRICT LOCATION CODE <br /> .......................................... -"ONTRACTOR/ SERVICE REQUESTOR <br /> CARD a: 9344 VISA <br /> ly CHECK If BILLING ADDRESS <br /> PAYMENT: CREDIT CHIP PKCONTRCi <br /> MOpE; ISSUER PHONE# �. <br /> ( 209) 765-7238 <br /> MID: IIEx41I30 FAx# <br /> RU1H CODE: 01606A STATE CA ZIP 95227-0279 <br /> CREDIT I, the undersigned property or business owner, operator or authorized agent of same, <br /> APP LABEL: VISA Dject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> CVM; NO SIO�'ECREDIT y business as identified on this form. <br /> RID; 80000000031010 tis application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> TC: 201509E8342 and FEDERAL laws. <br /> AMOUNT: $310,96 DATE: 111121 7-6... CARD APPROVED . OP OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> he BILLING PAR7�Y proof of authorization to sign is required Title <br /> �EIEi�iiEt3ii i311Ei� iil{3iiM311Ei�iI4i�Ei i31 %IfiE SE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> ize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> AMOUNT PAID: iuNTY ENvmoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> S �- /r — JVD • <br /> CUSTOMER COPY e�' PA Y <br /> Af <br /> Oft <br /> SA."'Ov <br /> Z � <br /> EMPLOYEE#: r S I <br /> ASSIGNED TO: EMPLOYEE#: v ,- N FZ <br /> Date Service Completed (if already completed): SERVICE CODE: �� 2 2, /'&�� <br /> Fee Amount: A�4 Amount Paid 062-fPayment Date �(� 2� <br /> Payment Type Invoice# � C�D( � Received By: <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />