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P2ost-jsbst <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />DATE: 12—f;2012 `L <br />SERVICE REQUEST # <br />�2O�SIollo� <br />oo�Q TrLcCK <br />/ t r <br />ZEg 3 <br />CITY I, -+x It 41,.E <br />STATE �u. ZIP ajrt/-L <br />OWNER/ OPERAT R <br />[� <br />1 A 1 <br />CHECK If BILLING ADDRESS E] <br />e Q+ <br />u a <br />FACILITY NAME <br />Payment Date <br />Z2 -- <br />SITE ADDRESS <br />Vi <br />Invoice # <br />Check # s <br />I Received By: <br />Street Number <br />Direction <br />Street Nam. <br />city <br />Zip Code <br />HOMEGQ{ r MAILING ADDRESS (If ifferent from Site Address) <br />� <br />1 1 r,7r� le Lb$'S' <br />C Street Number <br />Street Name <br />CITY <br />STATE <br />�ac1,�OrniC� <br />ZIP <br />aS�2-iZ <br />PHONE #i ExT' <br />Li <br />APN # <br />LAND USE APPLICATION <br /># <br />( Sl' I <br />PHONE #2 ECT. <br />I ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ///��� 1 <br />,n/ 1 A Ir, a L 4 . AA � 1 _ , �u� <br />1 �O�17 , 1 '1 'r 1 i I'1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />fg t'1 ie.rhoi.}�.iha� Gw:l:`.c <br />DATE: 12—f;2012 `L <br />PHONE# ECT' <br />SI> `fSq—:7-23- <br />HOME or MAILING ADDRESP <br />2R'Lq e r,'a4e MSS C -i- Cn. 9i 2 I'E— <br />/ t r <br />FAx# <br />( ) <br />CITY I, -+x It 41,.E <br />STATE �u. ZIP ajrt/-L <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 t <br />APPLICANT'S SIGNATURE: DATE: i 2 —'2� ^ ZZ <br />PROPERTY/ BustNESs OWNER' OPERATOR/ MANAGER ❑ OTUER AUTNoRizED AGENT ❑ <br />I,JAPPL7CANT 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 environmentaVsite 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 the or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: �. <br />VA r �" C6 rti 6h <br />.Zv <br />ACCEPTED BY: <br />EMPLOYEE #: 2-f 3 <br />DATE: 12—f;2012 `L <br />ASSIGNED TO: <br />n <br />l. C/ <br />/ t r <br />EMPLOYEE #: qS � <br />DATE: <br />Date Service Completed (ifalready completed): <br />SERVICE CODE: 61 <br />PIE: ' <br />Fee Amount: <br />Amount Paid // b� <br />Payment Date <br />Z2 -- <br />Payment Type <br />Vi <br />Invoice # <br />Check # s <br />I Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) S <br />