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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTDEPARTMENT <br />s SERVICE REQUEST <br />Type of Business or Property <br />PAYM <br />FACILITY ID # <br />SERVICE REQUEST <br />Q�vA\ GAS I C�evr <br />ACCEPTED BY: <br />`7 93$ <br />/# <br />S%� tJ.�'©1� <br />OWNER / OPERATOR <br />EXT. <br />CHECK If BILLING ADDRESS <br />IE AJ (� <br />VC's <br />(d -Ib gbif� <br />(0-i <br />Date Service Completed (if 41ready completed): <br />FAX # <br />Vi) <br />(011 -� N%�n <br />M "'C <br />Fee Amount: <br />FACILITY NAME <br />Amount Paid �cj o v <br />CITY \\ <br />tC•`(rC Y c�.� <br />STATE <br />Z1JP <br />Q <br />Invoice # <br />SITE ADDRESS <br />S <br />Tf d� V <br />`Tr o L <br />q� b <br />1 Street Number <br />Direction <br />p,C <br />Street Name <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address)1`1 <br />0 <br />Street Number <br />Street Name <br />CITY <br />eJo�c-tare O <br />STATE ZIP <br />GA (I -V3 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(1116 ) b`k 6 al b�,p <br />2- W2 - n Z o - 2s1 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />(1110) �:3y <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />� <br />PAYM <br />CHECK If BILLING ADDRESS <br />\ <br />APR - 3 Zona <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />BUSINESS NAME <br />PHONE# <br />EXT. <br />Wa <br />IE AJ (� <br />fib) <br />(d -Ib gbif� <br />HOME or MAILING ADDRES <br />Date Service Completed (if 41ready completed): <br />FAX # <br />Vi) <br />(011 -� N%�n <br />M "'C <br />Fee Amount: <br />(Q <br />Amount Paid �cj o v <br />CITY \\ <br />tC•`(rC Y c�.� <br />STATE <br />Z1JP <br />Q <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 or <br />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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: y 3 I01 <br />r <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. <br />TYPE OF SERVICE REQUESTED:� s 1— <br />PAYM <br />COMMENTS: <br />f <br />APR - 3 Zona <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />�( LI ( <br />EMPLOYEE #: 03 -2 - <br />DATE: <br />ASSIGNED TO: <br />IE AJ (� <br />EMPLOYEE #: S-(, 2 <br />DATE: [� 3 <br />/PIE: <br />Date Service Completed (if 41ready completed): <br />SERVICE CODE: /19 <br />7,3p o <br />Fee Amount: <br />cZ 4 , p� <br />Amount Paid �cj o v <br />Payment Date 1 3 / p 9- <br />Payment Type <br />C 1..I E C.tc_ <br />Invoice # <br />Check # <br />Received By: C� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />