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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />poM-NT <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />PHONE# <br />I Seo IS'�-A. <br />EXT. <br />- �1—t up <br />ru oo-2-��� <br />EMPLOYEE #: <br />FAX# <br />DO <br />CITY Fv f. O J ; \\ <br />STATE <br />ZIP C� Sc1 S <br />DATE: <br />OWNER i OPERATOR <br />SERVICE CODE: If 9 <br />P I E: y3 U <br />CHECK if BILLING ADDRESS� <br />FACILITY NAME r^ <br />Amount Paid <br />SITEADDRESS <br />Payment Date a <br />Payment Type <br />V/ <br />Invoice # <br />Street Number <br />Directlo <br />CRY <br />Z Coda <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PH014E#1 Ev. <br />APN # <br />LAND USE APPLICATION # <br />q <br />(3net) � A - a�Qtan <br />—3 <br />PHONIER En. <br />BOS DISTRICT <br />LOCATION CODE <br />( I <br />OL <br />5 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(� `� Y\ ��, r <br />poM-NT <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />RECEIVED <br />APR 12 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />PHONE# <br />I Seo IS'�-A. <br />EXT. <br />- �1—t up <br />HOME Or MAILING �A]DDRESS <br />EMPLOYEE #: <br />FAX# <br />DO <br />CITY Fv f. O J ; \\ <br />STATE <br />ZIP C� Sc1 S <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 1 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, STq DERAL laws. <br />APPLICANT'S SIGNATURE: (r+� DATE: Lk — V k — ;;> p l3 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE THERAUTHORIZEDAGENT a Pratn� <br />IfAPPL/CANT is nol 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: U"To <br />poM-NT <br />COMMENTS: <br />RECEIVED <br />APR 12 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />ACCEPTED BY: <br />ppp <br />M /I ,.M <br />V r7 L <br />EMPLOYEE #: <br />DATE: / / <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: If 9 <br />P I E: y3 U <br />Fee Amount: <br />37 S <br />Amount Paid <br />3 L —' <br />Payment Date a <br />Payment Type <br />V/ <br />Invoice # <br />Check # J <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />