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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business <br />E <br />COU <br />NTAL <br />or Property <br />CHECK IfBILLINGADDRESS <br />BUSINESS NAME <br />1)Iawan J <br />FACILITY ID # <br />a149zy) <br />ERVICE`� REEQiU,E�ST # <br />HOME or MAILING ADDRESS <br />( <br />ro <br />��J <br />FAX# <br />t ) <br />OCiD0�41 <br />�� <br />4 OIY, <br />OWNER / OPERATOR <br />CHECK ifBILLING ADDRESS <br />DATE:" <br />Date Service Completed (if already completed): --- <br />SERVICE CODE: �'�� _ZC�'� <br />PIE: <br />FACILITY NAME <br />�N <br />,/5 y t Z vi <br />r J <br />Amount P'a <br />^ C <br />Payment Date <br />211122� <br />SITE ADDRESS <br />Zq <br />5 <br />�� �4 <br />/� <br />/Name <br />Received By: <br />Street Number <br />pirecho <br />Street <br />CI <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />RE <br />street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 <br />EXT• <br />APN # <br />LAND USE APPLICATION # <br />SAE <br />( ) <br />dCAQU1N <br />PHONE #2 <br />EXT. <br />L �bbpEPA <br />BOS DISTRICT <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR yyy <br />�UaAek <br />^C JCC ? <br />wvl (�/ <br />CHECK IfBILLINGADDRESS <br />BUSINESS NAME <br />1)Iawan J <br />e�olev� ferV1Cel <br />a149zy) <br />PHONE# EXT, <br />0 -68992 <br />HOME or MAILING ADDRESS <br />( <br />ro <br />��J <br />FAX# <br />t ) <br />CITY D d l _ <br />STATE Gja zip Cl/SQ� <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge Lhat all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE:��j2+,�+�-' DATE:22- <br />3ROPERTY /BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ 07HERAUTHORIZED AGENT <br />❑ <br />If APPLICANT IS not th@ BILLING PAR7Y, proof of aUfhOrlZatlW" io SIgr1 IS re4Ulf Bd Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF <br />SERVICE REDUESTED: <br />(j 5'7- <br />COMMENTS: "C <br />go resile c� I ' � / <br />'A ! <br />��,,,M /, A "L M <br />�7 7�r <br />� 7 I ..5/ f 4 <br />ACCEPTED BY:/��� <br />��J <br />EMPLOYEE #: <br />DATE: -2�1 <br />ASSIGNED TO: ls� <br />EMPLOYEE#: <br />DATE:" <br />Date Service Completed (if already completed): --- <br />SERVICE CODE: �'�� _ZC�'� <br />PIE: <br />Fee Amount: 0 <br />Amount P'a <br />!�'� <br />Payment Date <br />211122� <br />Payment Type <br />Invoice # <br />Check .# 136 <br />3t3�z <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/06 <br />