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FACILITY ID # SERVICE REQUEST # <br />I 2- <br />CHECK If BILLING ADDRESS <br />YY\OLY\ Ve__e ck. q 3 337 <br />city ZIO Code <br />ACCEPTED By: 0C_ <br />ASSIGNED TO: c-O te-,4 <br />Date Service Completed (if already completed): <br />Fee Amount: I Sc <br />Payment Type <br />Invoice <br />EMPLOYEE #: 03 <br />EMPLOYEE #: z_L3 <br />SERVICE CODE: 5 a. <br />Payment Date <br />Check 1"-cl J2D ci./gt> <br />DATE: <br />DATE: <br />/0 <br />Received By: iya- <br />Amount Paid vls <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />OWNER / OPERATOR <br />0A(10 Ur\ -c1 <br />FACILITY NAME -e cc 0.. <br />SITE ADDRESS <br />- <br />Street Number <br />7 0 0 <br />I Direction <br />stV\ \Ck. <br />Street Name <br />HOME Or MAILING ADDRESS (If Different from Sits Address) <br />Street Number Street Name CITY <br />STATE ZIP <br />PHONE #1 <br />) <br />EXT. APN <br />U.Z. —1/ o <br />LAND USE APPLICATION # <br />PHONE #2 <br />) <br />EXT. BOS DISTRICT <br />CHECK If BILLING ADDRESS El <br />PHONE # EXT. <br />L-1 <br />FAX <br />(U)IC) <br />BILLING ACKNOWLEDGEMENT: 1, 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 COUNTY Ordinance Codes, Standards, STATE ale....1C.UEDERAL laws. <br />APPLICANT'S SIGNATU RE: ........./1/4WAVZ DATE: <br />PROPERTY/ BUSINESS OWNERCI OPERA'TOR / MANAGER 0 OTHER AUTHORIZED AGENTK disei 442444044,--f 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 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 ENVIROMENTAL HEALTH DEPARTME T as soon as it is availab e and at the same time it is <br />provided to me or my representative. P00 A4- Oii EL- cA-A) E c(C_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />CITY <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />11-ACU \ <br />BUSINESS NAME •Th <br />\rvt'_cc (3f-0 <br />HOME or MAILING ADDRESS <br />t ) rAY G C-C <br />G o STATE ZIP 9 -7 Lo <br />LOCA/ <br />ION CODE <br />\)-F) Gc-c.0- In, ct <br />I ka pE_A • <br />PAYM F RECEIVL <br />JUL 30 <br />SAN JOAQUIN C, ENVIRONMEN <br />HEALTH DEPAR -1-,