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%low II`It Y L If <br /> t <br /> i SAN JOAQUWOUNTY ENVIRONMENTAL HEALAEPARTMENT SEP 2 3 2015 <br /> SERVICE REQUEST ENVIRONMENTAL HEALTH <br /> RE Type of Business or Property FACILITY ID# SERVICE REQU ES <br /> LXALAlr <br /> OWNER/OPERATO ���j <br /> o` -e C 1I„v,` G s 1V, <br /> V CHECK if BILLING ADDRESS <br /> FACILITY NAME ,I \jam r' �f�/O,� VG p�/� <br /> SITE ADDRESS 3��Z l �4\ `l�(I�J �C�(M✓ I ��� <br /> Street Number Direction frost Name city I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 'A <br /> V4, <br /> '1 �f Street Number $�p��j treat Nams <br /> CITY Ij�J\ I,1 �� (i1 E) atjA / 'i1Jj— ZIV0-2 A <br /> PHONE#1 1J �+v EXT APN# LANDUSEAPPLICATION# �` <br /> 20 <br /> PHONE R EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � l j _ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME j-� i , ` - 5� ]_„� }� PHONE Exr <br /> HOME or MAILING ADDRES FAX# 2 4 <br /> CITY Ly` �TE ZIP -?&y2 <br /> � � - <br /> BILLING ACKN LEDGEMENT: 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDERAL I <br /> APPLICANT'S SIGNATURE: �'' DATE; `I <br /> PROPERTY/BUSINESS OWNER[3 'RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O) Br-111640V dO-- 411. <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 same time it is <br /> provided to me or my representative. wr <br /> TYPE OF SERVICE REQUESTED: wv S;/-eHd -t� �*Z PAYMENT <br /> COMMENTS: RECEIVED <br /> y/aft ls-- Al14r-- 74 AJSEP'2 3 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � - 4 &e ,4-0 1- ✓A- EMPLOYEE M 21d k-0 DATE: � a3 11,S— <br /> ASSIGNED TO: Ai#/AZ'-,I fe"a/3,0 EMPLOYEE#: 1168 DATE: �3 jS— <br /> Date Service Completed (if already completed): f/,�29/7j— SERVICE CODE: ,3 P 1 E: 44�'p7 <br /> Fee Amount: 4 3 �, _ Amount Paid f -7�1 Payment Date <br /> Payment Type Invoice# Check# 1400l Received By: 6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />