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SERVICE • <br />Type of Business or Property <br />yc'c3 rte, Itr�� <br />FACILITY ID # <br />SERVICE REQUEST # <br />�- <br />OWNER / OPERATOR <br />V -t o f <br />(J CC <br />CHECK If BILLING ADDRESS <br />FACIuTY NAME <br />U n rd S � 1 or rt�.�' <br />re" c, r`5 <br />FAx # <br />( <br />SITE ADDRESS <br />'I D Street Numtxr <br />Di 'on <br />GG L <br />t Noale <br />SAN JOAQUIN <br />ENS pNMENIAL <br />EP RWENT <br />C <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />t Number <br />E <br />treat Name <br />CITY <br />ASSIGNED TO: <br />STATE ZIP <br />PHONE #1 ExT• <br />c ) <br />APN # <br />Date Service Completed (if already Completed): <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR SERVICE e , , e <br />REQUESTOR A <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME.-- <br />-+-J n v I t o hz .e rl i� L <br />PHONE # <br />%5 <br />EXT. <br />5S ?- i o 2 <br />HoM or MAILING ADDRESS <br />v S 5 Ih, 15 s ►`,..� t r t_ p'h F� P 5 <br />FAx # <br />( <br />) 5 c 7 — i '7 o 2 <br />CITY y%J i J P rs I e�p— <br />STATE PA <br />Zip (1 2—! ac. <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 1 have prepared this appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAand FEDERAL laws. <br />APPLICANT'S SIGNATURE: ADATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ ® R AUTHORIZED AGENT <br />ffAPPL/CANT is not the BILLING PARTY proof of authorization to sign Is required Title <br />AUTHORIZATION ][Q MLEA5E IDJE RMATION: 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. , t\ A r--- € I T <br />TYPE OF SERVICE REQUESTED:RECOVED <br />COMMENTS: <br />2009 <br />COUNTY <br />SAN JOAQUIN <br />ENS pNMENIAL <br />EP RWENT <br />HEAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: / <br />P I E: <br />Fee Amount t <br />Amount Paid <br />Payment <br />bate \� <br />Payment Type V11, <br />Invoice # <br />I <br />Check #Received <br />I <br />By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />