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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHPARTMENT <br />SERVICE REQUEST <br />Type of Bus' ss or Property <br />I p I \ <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />too wl % S3 <br />OWNER 1 OPE TOR <br />`�1� . <br />CHECK if BILLING ADDRESS❑ <br />FAauTvNAMEV611-n- <br />HOrnE Or MAILING A DRESS �I ff <br />' / i/ <br />, Fes`/ / ) <br />SITE ADDRESS <br />0IStreet Number <br />S <br />Direction <br />I Street Name <br />q150 �f✓ <br />DATE: <br />Date Service Completed (i (ready completed): <br />� <br />i Code <br />SERVICE CODE (� <br />e <br />Fee Amount: O� <br />Amount Paid it ,;) v5- v 0 <br />HOME or MAILING ADDRESS (If Different fro <br />Site Address) t;'n; , <br />►►Numb <br />Invoice # <br />Check # (f <br />Sheet <br />Received By: <br />Street Name <br />(�/I A <br />f <br />STATE ZIP - --I� <br />PHONE #1 EXT. <br />APIN f# <br />LAND USE APPLICATION # <br />PHONE2 EXT. <br />B DISTRICT f, <br />LOCATION CODE <br />CONTRACTOR/ / SERVICE RE, QUESTOR <br />REQUESTOR \ lJ <br />I p I \ <br />RECEIvEn <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />�. <br />all <br />ACCEPTED B ' <br />PHOtyE <br />( E, <br />/} xT. <br />'4 55 <br />HOrnE Or MAILING A DRESS �I ff <br />' / i/ <br />, Fes`/ / ) <br />7 „ I <br />CXZIP <br />CITY <br />r STATE <br />q150 �f✓ <br />i <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 all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST E and FEI)ERAL laws. <br />APPLICANT'S SIGNATURE: ' 1 1 it I l� V DATE: C <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ET e Qj a <br />[f 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 loca ed 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 />nrovide.ri to me or my reDresentative. nsvlutFNT <br />TYPE OF SERVICE REQUESTED: US � <br />� � <br />RECEIvEn <br />COMMENTS: <br />MAY 21 2012. <br />$A:'u-AQu@M r-01-1117"IF, *IR,)NMnNTAL <br />HEALTH 1FRARTMEtr7 <br />ACCEPTED B ' <br />EMPLOYEE #:q O� 5->:2 <br />DATE: 2l Z <br />ASSIGNED TO: <br />EMPLOYEE q z- <br />DATE: <br />Date Service Completed (i (ready completed): <br />SERVICE CODE (� <br />P I E O� <br />Fee Amount: O� <br />Amount Paid it ,;) v5- v 0 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # (f <br />Received By: <br />EHL) 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />