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SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECKIf BILLINGADORESS <br />FACILITf ID # <br />�I <br />� r <br />SERVICE REQUEST # <br />PHONE# EXT' <br />91 53 7 -65-00 <br />HOME or MAILING ADDRESS <br />DATE: Zq ao <br />Date Ser Act Completed (if ]Irsady G,mpleted): <br />FAX# <br />$9-Ov F.7k G Ci,' <br />OWNER/ OPERATOR <br />Fee Amount: Amount Paid <br />Q -D <br />- CHECK if BILLING ADDRESS❑ <br />FACIPU? r NAME <br />STATE /� ZIP q5 30 <br />L'e,e <br />SITEADDRESS <br />L✓ <br />/ItQ� (� �s33b <br />Street Number <br />Direction `� <br />"K Coln Street Name <br />CI ZI LOCe <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Neme <br />Cin, <br />STATE ZIP <br />PHONE #1 <br />( ) <br />E`er <br />APN #12 2� tO <br />--te -off <br />LAND USE APPLICATION # <br />PHDNE#2 <br />( ) <br />ExT. <br />BOS DISTRICT_ <br />S <br />LOC TI CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUER / <br />Ward <br />CHECKIf BILLINGADORESS <br />BUSINESS NAME// <br />A)-4114 cwt & <br />�I <br />� r <br />n,TE; 14' <br />PHONE# EXT' <br />91 53 7 -65-00 <br />HOME or MAILING ADDRESS <br />DATE: Zq ao <br />Date Ser Act Completed (if ]Irsady G,mpleted): <br />FAX# <br />$9-Ov F.7k G Ci,' <br />PIE: <br />G <br />Fee Amount: Amount Paid <br />Q -D <br />CITY <br />STATE /� ZIP q5 30 <br />L'e,e <br />Check# 1001(0 <br />BILLING ACKNOWLEDGEMENT: I, die 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 JOAQIJrra <br />COHN-, Y Ordinance Codes, StaHJards, S TATE and FEDERAL. laws. 0A <br />APPLIC .ANT'S SIGNATURE: �LiL� / W Z °�\ DATE: <br />L'ROPG1iT v I JJI,SINIeS O\wvRR❑ OPERArOR/MANAGER❑ OTHERAU7'HORIZEDAGENTX <br />rf PPLICANT is not the BILLING PAR TP proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locaied 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 tiie SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and RT the same time it is <br />provided to n'.- or my representative. <br />TYPE OF SERVICE REQUESTED: P-,ECIP FEEA-c� [2-#c+u OO H PL -4N Crt-E�C� <br />pAYMENT I <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />APR 0 6 2009 1 <br />H,"N ,]np.C)JIN COUIdTY <br />ONMEI`RAL I <br />, <br />ACCEPTED BY! O 1, L v Er &e-+ <br />Ew LDY=_E #: p 3 2, - <br />n,TE; 14' <br />ASSIGNEDTO: Es <br />EMPLOYEE <br />DATE: Zq ao <br />Date Ser Act Completed (if ]Irsady G,mpleted): <br />SEP.`!:CE CCCE: 52.•% <br />PIE: <br />G <br />Fee Amount: Amount Paid <br />Q -D <br />Payment Date <br />Payment Type ✓ <br />invoice# <br />Check# 1001(0 <br />Received. By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />