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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH*DtPARTMENT <br />SERVICE REQUEST <br />TypX3f Busine s Or Property <br />IliS7aP rry�. <br />BUSINESS .{� 1 j / <br />NAME!�P.'S/Q1A <br />FACILITY ID # <br />New <br />HOMAILING A DUEStteli <br />SERVICE REQUEST # <br />S,0bTO' �16I <br />OWNER / OPERATOR <br />CITY Qil STATE ZIP �6 <br />CHECK If BILLING ADORESSE] <br />FACILITY NAME <br />S8et /V� <br />SITE ADDRESS ICE, Numbe r <br />Olrec[ion <br />� `I `I Name� <br />r <br />� <br />f'—" � <br />5 33 1 <br />Zi Coda <br />Or MAI_LINOi,P anc,(If Delfferen/t�fl�m Site Address)'(1�'7-'-7 <br />ITX4•/1 y� -IY 7 StreTet� NuLmber <br />�bvs;p,es <br />{ b'' <br />Street Name <br />CITT emG cI-(. 0. <br />t9 <br />TATE <br />IP(?L157 4 <br />PHONE ) ENT, <br />('151!O(0 --f—,g&/Ic� <br />Fee Amount: <br />APN # <br />LAND USE APPLICATION #Z <br />PH0ONEE#2 EXT. <br />( <br />Payment Type SGL <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i Q <br />n CHECK If BILLING ADDRESS <br />BUSINESS .{� 1 j / <br />NAME!�P.'S/Q1A <br />PHONE# Ex,. <br />HOMAILING A DUEStteli <br />_ r <br />(Fac. <br />osSfvIce plans} <br />FAX# <br />CITY Qil STATE ZIP �6 <br />BILLING ACKNOWLEDGEMENT: 1, 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 />1 also certify that 1 have pre t iirefil s app lion and that e-w68tZD4i erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Co Standards, STATE an FEDE <br />APPLICANT'S SIGN DATErr•��7 /!��,, '' 1 Z�0 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT�PyL�L. <br />/(APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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 />T va', CSC <br />"AYM <br />ENT <br />COMMENTS: <br />�j lcty\ ��2Gk <br />_ r <br />(Fac. <br />osSfvIce plans} <br />IDEC212015 <br />EHNHOqOE AE TY <br />Tk& <br />TMFA7 <br />ACCEPTED BY: 11 <br />EMPLOYEE #: <br />DATE: 12.- Z(_ 1-) <br />ASSIGNED TO: <br />EMPLOYEE #: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ej1� <br />P / E: 1 (1U ) <br />Fee Amount: <br />Amount Paid <br />Payment Type SGL <br />Invoice # <br />Check # <br />Received By: 1116. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />