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SAN JOAQUIUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />N OQ <br />SERVICE REQUEST 0 <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />C' 3 "0 <br />JAN 9 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FAX # <br />001) /— &3yg <br />CITY !� / _ _ _ <br />STAT ZIP6 s� <br />.)a5 <br />DATE: / q -c - <br />ASSIGNED TO: <br />N u <br />OWNER / OPERATOR <br />M%� �1; / <br />c C1 <br />DATE: - dy% <br />ooe <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: 19k <br />PIE: 2-3 <br />Fee Amount: <br />14 <br />�t^t If, av <br />(�' (' f <br />SITE ADDRESS �g ,f/Ijl� ? 7 C /lU� <br />, , / <br />�tF�1 CCS �f 34' <br />Street umber Direction <br />Street Name <br />Ci Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Check # \ 25 Z 3 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />(.� d S 1�5--dL(DI �kloq <br />APN # <br />2-21-- ISO -OA�7 <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />1,57-3 � -a <br />BOS DISTRICT <br />LOCATION C DE <br />a a 11 <br />.5" <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR IC1aL� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEPHONE# <br />V Con �nXCI&-e- <br />COMMENTS: <br />ExT. <br />0A <br />HOME or MAILING ADDRESS r <br />r- S �1LLArn by -r' <br />JAN 9 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FAX # <br />001) /— &3yg <br />CITY !� / _ _ _ <br />STAT ZIP6 s� <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 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: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTO Sert)tG=e epY(Z�, YlC <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. PA V I\ /I I= n IT <br />TYPE OF SERVICE REQUESTED: (� S �J j <br />/1 / <br />RECEIVE D <br />COMMENTS: <br />JAN 9 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />D L j �C <br />EMPLOYEE #: 03-2-1 <br />DATE: / q -c - <br />ASSIGNED TO: <br />N u <br />EMPLOYEE #: Z �-7 d <br />DATE: - dy% <br />ooe <br />Date Service Completed (if already completed): <br />SERVICE CODE: 19k <br />PIE: 2-3 <br />Fee Amount: <br />14 <br />�t^t If, av <br />Amount Paid <br />Payment Date <br />\ C� a g <br />Payment Type <br />�� <br />Invoice # <br />Check # \ 25 Z 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />