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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C O F / q -7a3 <br /> OWNER/OPERATO <br /> e—ti1pr CHECK if BILLING ADDRESS <br /> FACIL Y NAME ALJ <br /> U <br /> SITE ADDRESS <br /> Street Number Direction "C tr et Name ip Code <br /> HOME or <br /> MAILINGADDRESS <br /> _(iif.Different f'ro`mt,Site Address) / O` �c �� <br /> `` ` '�/`�—V l�` �O Street Number Stre t Name <br /> CITY �G�n <br /> STATE 5350 <br /> PHONE#1 ,JG EXT. APN# LAND USE APPLICATION# <br /> (adq ) S�-(q-56(1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> SeeL-A I A D CHECK if BILLING ADDRESS <br /> BUSINESS(NAME PHONE# EXT. <br /> L C Gerv�c,eS 5,A 444- <br /> HOME Or MAILING ADDRESS FAX# <br /> -1:11818-7 N. (559 ) "44- <br /> CITY P,ep5KO STATE CA <br /> zip q3-1n <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 TATE and F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: l�-w �tlr <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® CCA- .r�c._,�Q� <br /> If APPLICANT is not the BILLING PART)',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: 1►J 59G-kC C.1., or <br /> M A 1k(. t� pClrs . <br /> COMMENTS: e 1Z ot-eutts Reaue5`CW-e ujkkk P' Vt«COL) <br /> QeebP�— vxc-44M -va ee s�cI <br /> EGgIVED <br /> veeoer Coca Se &c JAN 21 2011 <br /> SAN NVIAROUIN MENTOUNry <br /> AL <br /> ACCEPTED BY: �D�JELZ <br /> EMPLOYEE#: 4 0SDATEH� I 5,it <br /> ASSIGNED TO: A,IQ be, EMPLOYEE#: yl (, 70' DATE: l2 I aC��� <br /> Date Service Completed (if already Completed): SERVICE CODE: Cf SJ P/E: <br /> Fee Amount: 36,&Ct' Amount Paid -3 b— Payment Date \ Z\ \ <br /> Payment Type �� Invoice# Check# 5 1 0 3 3 Received By: V(7rr— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />