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SAN JOAQUIN 7UNTY ENVIRONMENTAL HEALTI" --EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />SWJ�oo <br />S �'jF7—j�—D F' C % <br />FACILITY ID # <br />PAYMENT <br />RECEIVED <br />SERVICE REQUEST # <br />5Koo %,2 (v d <br />OWNER / OPERATOR <br />f�*1t IIU/ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS� 31 � <br />Street Number <br />Direction <br />v" Street Name <br />cityZi <br />9MM) <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />O I / c vgt � <br />Street Name <br />CITY <br />0,3 <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />DATE: 7 L <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU ESTOR �iC C�"U CHECK if BILLING ADDRESS <br />1l � <br />BUSINESS NAME ( PHONE jam' <br />HOME Or MAILING ADDRES FAX # <br />( l) — 6 <br />CITYSTATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or auttiorizea agent of same, <br />acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />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. <br />APPLICANT'S SIGNATURE: 41-m DATE:PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENThe &)U Q <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 />TYPE OF SERVICE REQUESTED: U <br />S �'jF7—j�—D F' C % <br />PAYMENT <br />RECEIVED <br />COMMENTS: <br />JUL — p 2011 <br />SAN-JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />O I / c vgt � <br />EMPLOYEE #: <br />0,3 <br />DATE: 7 f' `% <br />ASSIGNED TO: <br />6Ac—cLt—S <br />EMPLOYEE#: <br />C C43,6 <br />DATE: 7 L <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: -2-394 <br />Fee Amount: <br />a 3 6P6 � <br />Amount Paid � 3 � L- p � <br />Payment Date <br />`7 fir( <br />Payment Type✓ <br />Invoice # <br />Check # <br />(0 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />