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V <br />Type of Business r Property <br />FACILITY ID # <br />SERVICE REQUEST #A <br />9 <br />OWNER / OPERATOR <br />ACCEPTED BY:> EMPLOYEE #: ( <br />CHECK if BILUNG ADDRESS <br />FACILITY NAME <br />�z <br />ASSIGNED TO: EMPLOYEE #: 7 <br />SITE ADDRESS <br />�' <br />''�' <br />SERVICE CODE: r <br />, Street Number>�dislft`Nime`Ci <br />P 1 E. C) <br />Cods <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Payment Type ✓ <br />Invoice # <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPUCATION # <br />�► 44(-, - ef /) I <br />PHONE #2 Err. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU5?TOR <br />/% / r CHECK If BILUNG ADDRESS <br />E t!�C7777 <br />C— rwnee 5- 1 C_ <br />77 <br />Y6 �9 <br />FHOMMEorGADDRESS F �/ 4,9 �o n > `� le <br />J STATE ZIP o� ,-� <br />ILLING 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 />r 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, STATE d FED /11aS. <br />1 APPLICANT'S SIGNATURE: <br />DATE:�/ <ra <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT O C d L' 1 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION 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 sante time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:AerIc-2t <br />COMMENTS: <br />O <br />� �� � 11�ls � colt 3 t3 I -S <br />ACCEPTED BY:> EMPLOYEE #: ( <br />DATE: p <br />�z <br />ASSIGNED TO: EMPLOYEE #: 7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: r <br />C <br />P 1 E. C) <br />Fee Amount: -;17 <br />Amount Paid / <br />Payment Date 7 la -Z(6 Lf <br />Payment Type ✓ <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 ' ff i6j��l°Y PAYMEN l <br />` --^ RECEIVED SR FORM (Golden <br />REVISED 11/17/2003 <br />c / <br />��� u ,�tl 514" SAN JOAQUIN COUNTY <br />At'�`�yd P('D a-� / ENVIRONMFNTAL <br />hll .>CAITu nF-PARTMENT <br />