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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/��J / / ■I ` <br />FACILITY ID # <br />�Co 5-7SI<o <br />BU INESS NAME <br />SERVICE REQUEST # <br />O t'vZ11 Iola <br />OWNER I OPERATOR <br />S , �—'T� <br />CHECK if BILLING ADDRESS <br />FACIL NAME _--- <br />avku <br />SITE ADDRESS <br />v Street Number <br />I Direction <br />EiUZaLnZ46-Zi <br />CITY <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />i treat Narne <br />CITY <br />C-, -�-1 ii I <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT- <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE(`STOR �/ry) <br />/��J / / ■I ` <br />CHECK if BILLING ADDRESS E] <br />BU INESS NAME <br />CEIVED <br />JUN 2 7 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # <br />> EXT. <br />EMPLOYEE #: 01 S <br />DATE: <br />ASSIGNED TO: <br />HOME Or '-teLING ADDRESS <br />CJ <br />DATE: <br />FAX # <br />CITY <br />STAT <br />zip <br />BILLING ACKNOWLEDGEMENT: 1, 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 aal SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard E ander EDERAL S. <br />APPLICANT'S SIGNATURE: c_ `y_ DATE: —& Z 1 <br />PROPERTY/ BUSINESS OWNER'— OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APP'.ICAw is not the BILLING PARTY, proof of authorization to sign is re4uired 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 />PAYMENT <br />COMMENTS -1-0 �e ick ��I� ,��s�i.` Cis,,,-� ,( %jt3Gx�2 <br />(�e <br />CEIVED <br />JUN 2 7 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: 01 S <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: (P Y <br />DATE: <br />Date Service Completed ( beady completed): <br />SERVICE CODE: ' <br />P 1 E:Z <br />Fee Amount: <br />Amount Paid o. D-0 <br />payment Date <br />C-, -�-1 ii I <br />Payment Type ✓ <br />Invoice # <br />Check # `�'� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />