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SAN JOAQU4UNTY ENVIRONMENTAL HEALTH*ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME _ _ , l <br />FACILITY ID # <br />PHExT. <br />91� ��-5' lS <br />SERVICE REQUEST # <br />19'91 � <br />4rele- <br />(9 # ) 9e) ��� <br />CITY 6 C s", <br />STATE /%4 ZIP '75;7,6.37 <br />DATE: / 2-/t D <br />[� <br />n 5 <br />(? A G,q p 1 •7 - <br />EMPLOYEE #: [� �� <br />DATE: <br />1 <br />Date Service Completed (if already Completed): <br />'!5 <br />OWNER / OPERATOR <br />C ' <br />�� <br />P 1 E: 2306, <br />CHECK if BILLING ADDRESS <br />bD <br />/�� <br />5 DPayment <br />Date <br />FACILITY NAME <br />Payment Type <br />SITE ADDRESS jJ�20 <br />7s <br />- <br />` i -) <br />-p012 + V I s <br />/ <br />/?o <br />7 <br />t Number <br />Direction <br />Street <br />Name <br />C' <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE N <br />EXT• <br />APN # <br />LAND USE APPLICATION # <br />(Ao) -/9G-0 <br />1 022q- <br />i7o_t2- <br />PHONE V <br />Err. <br />BIDS DISTRICT <br />LOCATION CODE <br />( ) <br />G-^ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR // <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME _ _ , l <br />PHExT. <br />91� ��-5' lS <br />HOME Or MAILING ADDRESSPtd 0o x cp' y' <br />/ <br />ACCEPTED BY: <br />(9 # ) 9e) ��� <br />CITY 6 C s", <br />STATE /%4 ZIP '75;7,6.37 <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 an t at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT d F L laws. <br />APPLICANT'S SIGNATURE: DATE: 30 .Ci 9 <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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. s,( `7 /dt 10,1 n/ G- Ae f>0,J—[ AL <br />TYPE OF SERVICE REQUESTED: /N S7�-GL�Q(�/ T <br />/ �%(f j� <br />COMMENTS: <br />RECEIVED <br />DEC -1 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />O i.l v E- <br />EMPLOYEE #: J � Z <br />vJ/ <br />DATE: / 2-/t D <br />[� <br />ASSIGNED TO: <br />(? A G,q p 1 •7 - <br />EMPLOYEE #: [� �� <br />DATE: <br />1 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 9 6 <br />P 1 E: 2306, <br />Fee Amount: <br />bD <br />Amount Paid <br />5 DPayment <br />Date <br />�2 , <br />Payment Type <br />Invoice # <br />Check # Lfgg3 <br />Received By: <br />EHD 48-02-025 SR F001(Golden Rod) <br />REVISED 11/17/2003 <br />