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• 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s S tc, t- 34:;,2-7 -5 R-60 6 l 7q <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> FACILITY NAME 10� <br /> SITE ADDRESS -7112S- TfIC4( ,3 01VC) tnG y y.��-76 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �mw�n CHECK if BILLING ADDRESS O <br /> nd Q <br /> BUSINESS NAME PH NE# ExT. <br /> Ciettler- fec4n 1 e- Zs' s"s-1 - 73 ss <br /> HOME or MAILING ADDRESS FAX# <br /> —67(-1'? S:cn- Cour Sv.' ( 9&-) <br /> CITY0 V b) r� STATE e C4. ZIP <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, STATE EDERAL laws. <br /> APPLICANT'S SIGNATURE� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTr- <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: <br /> COMMENTS: VeP l CCe C7 J-r- <br /> 1 <br /> ergo per-G,b le, <br /> RECEIVED <br /> JAN - 7 2011 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: l .o d EMPLOYEE#: O3Z DATE. / P E� <br /> ASSIGNED TO: EMPLOYEE#: —2&9t*6 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:23 p(' <br /> Fee Amount: X66�'�' Amount Paid —3,66©5 <br /> Payment Date <br /> man, 6. .10/j <br /> Payment TypeCL,�,,-i Garel Invoice# etTeft# C Q Received By: �r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> l <br />