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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� <br /> OWNER/OPERATOR r� <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY E <br /> s � 1 <br /> SITE ADDRESS '`�1II�,L�11. C- <br /> "Street N�umJber Direction vv Street Name O �Cltl•�—\lJ� �Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number J�Stlre�el Name `�J <br /> CITY STATE Zip 5a l <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> ill - �a 37 -2-6,o-(2- <br /> PHONE#2 EXT. BOS DISTRICT ) LOCATION CODE <br /> ( ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 1 <br /> CITY 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 or my business as identified on this form. <br /> 1 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 Iaws. ��,,yy�� �n <br /> APPLICANT'S SIGNATURE: �rr`,S � le L DATE: ad : 0 /,00U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> rfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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 t0 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: f=0 Z /3 G©/lJ X LLC-%)4- 77© <br /> PAYMENT <br /> COMMENTS: t[_(� p PES 77-EE 441s7A-c1-�/ RECE IVED <br /> 7-7-C es r-4 GL`- -y A-s ,t- S"t4 4�-rla JAN 3 0 2012 <br /> SAN JOAQu N coUNTY <br /> ENVIRON ENTAL <br /> HEALTHOERARrMEN, <br /> ACCEPTED BY: TO C.c V E r AgA EMPLOYEE#: b 3 ' J DATE: 2o <br /> `2-_ <br /> ASSIGNED TO: Pci-0/{Aa—fc:FA .CC TZ EMPLOYEE#: 33% DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: p� /E: /(,o Z <br /> Fee Amount: ZS—_ Ol0 Amount Paid `�7 aS` Payment Date a Z� <br /> Payment Type (o2ASA Invoice# Check# Rec i ed By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />