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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ^ 1 <br /> SERVICE REQUEST y 110F17 �C <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ./IA 1�`I� .C� ,/tA,L C A� CHECK If BILLING ADDRESS <br /> FACILITY NAME Nn '►(1 A \4 CA�-/"L�'L A� 1� <br /> SITE ADDRESS/ 1'�` <br /> Lq 1-7 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING AgDRESS,(If Llifferept fjom Site Address) �J• 9 C 1 <br /> SVeet Number t et ame ? <br /> CITY STATE G ryA ZIP <br /> PHONE# / �� /ar' APN# LAND USE APPLICATION# <br /> PHONE#2 S ExT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M^ 1Lk .� � / ^ <br /> �C f� LIEF�' CHECK If BILLING ADD�REySS <br /> BUSINESS NAME LC V <br /> H or MAIL G ADDR S r G 7 u (� I��r N fes# <br /> S <br /> CITY 1 ..(%` STATE ZIP �� D <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 <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 laws. /' �y <br /> APPLICANT'S SIGNATURE: C DATE: (0.2-2 -ZZ <br /> PROPERTY/BUSINESS OW OPERATOR/MANAGER ❑ OTHERAUTI ZED AGENT 13 <br /> /,fAPPLICANT is not the BLLLINGPARTY 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 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. P,4 <br /> TYPE OF SERVICE REQUESTED: t-4C o ECEIV <br /> COMMENTS: AUG 2 9 <br /> 2012 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL TY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: '\ EMPLOYEE M 1-7&t DATE: Z 7L <br /> ASSIGNED TO: ✓ EMPLOYEE M g E 2 rs DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 061 P ft: <br /> Fee Amount: 156 1 Amount Paid /S6. UC) Payment Date J L 2 <br /> Payment Type CkInvoice# Check# S7 7S Rece ed By: <br /> EHD 48-02-025 (l �r1 1�� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1y yl <br />