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J <br />l <br />CA " q 5-5- -- 6 n `4- Ly-- 1'5P -tel <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENRIT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: <br />FACILITY ID # <br />f i <br />SERVICE REQUEST # <br />��estC�Q Y1�C l <br />EMPLOYEE M <br />DATE: I� I <br />ASSIGNED TO: <br />�Q08?3/41 <br />9W4ER / OPERATO <br />C, <br />�� <br />DATE: <br />S <br />CHECK If BILLING ADDRESS <br />Fee Amount: <br />( J`� <br />--FACILITY NAME <br />Payment Date - <br />Payment Type <br />SITE ADDRESS <br />15C, I <br />Check #�i� <br />/ <br />1 <br />Cl <br />CCE 1 �1I o <br />�52 2G <br />J Street Number <br />Direction <br />C l <br />(� Street Nam <br />CI <br />Zt Code <br />HOME Or MAILING ADDRESS (If Different from Site Aef es ) <br />�0l <br />1 < < <br />Street Number <br />Street Name <br />ITY, <br />L <br />$TATE � zip� � �C L� <br />`(' <br />HONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />vt>T 401-22 <br />PHONE #2 <br />EXT. <br />BOS DISTRICTLOCAAONJODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING -AD DRESS <br />BUSINESS NAME <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY <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 or <br />activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared chis application and that the work to be performed will be done in accordance with all SAN J,.AQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />j <br />APPLICANT'S SIGNATOR—,L�� ;�,� tet. DAfe .X��' / 5 <br />PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: j i' (,v(`� to LA <br />COMMENTS: <br />!/ L `` <br />f i <br />ACCEPTED SY: � <br />EMPLOYEE M <br />DATE: I� I <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): I SERVICE CODE: <br />Fee Amount: <br />( J`� <br />Amount Paid C--� <br />Payment Date - <br />Payment Type <br />Invoice # <br />Check #�i� <br />Received By: <br />EHD 48-02-025 <br />07/17/08 <br />ri <br />PAYMENT <br />RECEIVED SR FORM (Golden Rod) <br />SEP 15 2015 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />