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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />TypeBusine11ke\-) <br />00A <br />Property - <br />FACILITY ID # <br />3g 3 5 <br />SERVICE REQUEST# <br />s'� Do �ot�'3eZ <br />OWNEA OP RATOR <br />,n �J <br />CHECK if BILLING ADDRESSO <br />FACILITY <br />i <br />SITE ADDRESS <br />Street Number <br />�/e)AV�/ // <br />�-Ofl`ection <br />/1,S/ <br />-�! /Street Name <br />q <br />"`� `� <br />tWdee <br />HOME or MAILING ADDRESS (If Different from Site. Address) <br />Street Number <br />Street Name <br />CITY <br />Date Service Completed (if already completed):, <br />STATE ZIP <br />PHONE #1 <br />V <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />( ) <br />Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />1" t(lil 337 <br />HOME or MAILING ESS f� <br />FAX <br />CITY <br />STATE 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 ormy b m , s as identified on this form. <br />I also certify that I have prepared this applic=ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar STA7IE and FEDERA7/1 APPLICANT'S SIGNATURE:DATE: lX ! �-31AID <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required"'TitIe <br />AUTHORISATION TO RELEASE INFORMATION: When applicable,1, 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 />T <br />COMMENTS <br />RE—CEIV <br />JUN 2 3 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:� <br />EMPLOYEE #: � <br />DATE: <br />ASSIGNED TO: <br />L <br />EMPLOYEE #: r C.� ZZ <br />DATE: Z3�� <br />Date Service Completed (if already completed):, <br />SERVICECODE: Ay <br />V <br />P / E: oe <br />Fee Amount: a <br />Amount Paid <br />3 () q <br />Payment Date /_-q <br />Payment Type✓ <br />Invoice # <br />Check # 1 41 1 <br />Received By: � <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />