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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS I J <br />FACILITY ID # <br />TYPE OF SERVICE REQUESTED: ��S <br />SERVICE REQUEST # <br />A-% 5TA-.0 NJ <br />COMMENTS: C4- �j Q ((� <br />uRECEIVED <br />3 S 0.3 <br />CITY S wv— ` O up- <br />5,200 5'"s-0 <br />OWNER /OPERATOR <br />/ <br />CHECK if BILLING ADDRESS® <br />FACILITY NAME <br />PERMIT/SERVICES <br />SITE ADDRESS <br />W <br />,i.I. -St <br />6 <br />l <br />Street Number <br />Direction <br />reeeet Name <br />Ci <br />ZiaJCode <br />HOME Or MAILING ADDRESS (if Different from <br />Site Address) <br />DATE: ! <br />Date Service Completed (if already completed): <br />SERVICE CODE: t 4 d <br />Street Number <br />P!1 E: �2 Q� <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#t EXT• <br />Payment Type ✓ <br />APN # <br />LAND USE APPLICATION # <br />(.Wq) . � 3 0 - `'c <br />Receiveld By: <br />2, 3 2. - /. 7ti) _ 247 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATIOI%�ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR M <br />CHECK If BILLING ADDRESS I J <br />BUSINESS NAME �+�r _ ' J . <br />TYPE OF SERVICE REQUESTED: ��S <br />PNpN +�C Exr. <br />yAx## <br />HOME or MAILING ADDRESS <br />60 Qu�llt" Ac) -e. <br />COMMENTS: C4- �j Q ((� <br />uRECEIVED <br />F <br />(�ft ) a(3 - lQdQ4 <br />CITY S wv— ` O up- <br />STATE C yi ZIP 1?v <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 />1 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. <br />GNATREAPPLICANT'S SIY-ATE.... / <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT RL Li a i`(QI ( j uN'C,xcr <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 />p <br />TYPE OF SERVICE REQUESTED: ��S <br />% 0AC7 F/ T <br />COMMENTS: C4- �j Q ((� <br />uRECEIVED <br />/�� o�S <br />h- <br />v Y� Q :SIT su <br />�/ <br />NOV O 9 2007 <br />NOV 9 2007 <br />ENVIRONMENT HEALTH. <br />PERMIT/SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY: v�( (�� <br />EMPLOYEE k'EALTrE-PNigT <br />(/ <br />DATE: <br />7 '0.. <br />ASSIGNED TO: >-2 <br />EMPLOYEE #: f� /_ c�1 <br />DATE: ! <br />Date Service Completed (if already completed): <br />SERVICE CODE: t 4 d <br />P!1 E: �2 Q� <br />Fee Amount: ! <br />Amount Paid a2� �' _ <br />Payment Date <br />11 <br />Payment Type ✓ <br />Invoice # <br />Check # Zt� 2— <br />Receiveld By: <br />EHD 48-02-025 SR FORM (Golden Roil) <br />REVISED 11/17/2003 <br />