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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST ,G p/mg w <br />Type of Business or Property <br />FACILITY ID=SERVICE <br />REQUEST# <br />K <br />� <br />iz� <br />l1� <br />co o ri <br />OWNER/ OPERATOR <br />DATE; O <br />FAX# <br />( ) <br />'CITY / <br />STATE ZIP <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />CHECK If <br />BILLING ADDRESS <br />u u�/ <br />P / E; <br />Ivo <br />Fee Amount: 192-- <br />Amount Paid <br />FACILITY NAME <br />Payment Date <br />l Q <br />-q- '2 -! <br />Payment Type cj Q <br />✓l <br />Invoice # <br />Check # <br />Received By: <br />SITEADDRESS - - C, � 1 <br />30 <br />S <br />tiv�n <br />treet Number <br />Dlmctfon <br />Slreet Name <br />Cit <br />Zip Code <br />HOME Dr MAILING ADDRESS (If Different from Site Address) <br />CA LiD <br />V ✓J <br />- <br />Streat Number <br />Strela/tName <br />STATE <br />ZIP <br />PH NE#t EXr. <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Ezr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />'I CHECK If BILLING ADDRESS <br />V <br />BU SINE55 NAME v <br />K <br />PHONE# ExT <br />J <br />l1� <br />co o ri <br />HOME Or MAILING ADDRESS <br />DATE; O <br />FAX# <br />( ) <br />'CITY / <br />STATE ZIP <br />BILLING ACIQVOWLEDGEMENT: 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 <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL la s. <br />APPLICANT'S SIGNATURE: —K7—( �,DATE 2 <br />PROPERTY/ BUSINESS OTVNER❑ <br />OPERATOR/ MANAGER ❑ OTBERAUTHORIZEDAGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 to 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:ftd <br />PAY <br />COMMENTS: <br />NECE <br />�D <br />S JOAQUIN CSU <br />HEgt THO NME T� tV <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE; O <br />/r <br />ASSIGNED TO: �/ I <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E; <br />Ivo <br />Fee Amount: 192-- <br />Amount Paid <br />15a _ <br />Payment Date <br />l Q <br />-q- '2 -! <br />Payment Type cj Q <br />Invoice # <br />Check # <br />Received By: <br />EHD 45-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />