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SAN JOAQUIN ,OUNTY ENVIRONMENTAL HEALTH DEI-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Svc <br />FACILITY ID # <br />nnSERVICE REQUEST #i <br />Sce Gro a w l< <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # ExT' <br />20 �t q5- 4 g I <br />OWNER I OPERATOR <br />FAX# <br />( ) <br />�(6t 7-M I A <br />� S �cn <br />CHECK If BILLING ADDRESS <br />I. CIL l l/ L <br />ASSIGNED TO: <br />FACILITY NAME <br />cc. cn L010 lei ai o v S <br />EMPLOYEE#: <br />SITE ADDRE <br />1U�eS'f["h.2- <br />Al— <br />/DDU <br />SERVICECODe <br />PIE: <br />Street Number <br />Dlrattion <br />Street Name <br />I S �, <br />Payment Date <br />y Code <br />HOME orMAILINGADDRESS (If Different from Site Address) <br />Invoice # <br />�2 0 1 " 6 GY 1 b n'Q."r- l Street Number <br />Street Name <br />CIN <br />STATE ZIP <br />CA as ao le <br />PHONE#1 Ex, <br />APN# <br />.I <br />LAND USE APPLICATION# <br />(z0() 3 - 9 i L-( <br />, I ► -13�0 <br />PHONE #2 EXT. <br />( ) `l03- LII1�( <br />BOS DISTRIC <br />Fa <br />LOCATION CODE <br />D <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 11 II <br />g(I Z <br />CHECK if BILLING A111EISM <br />BUSINESS NAME <br />i trt /f'W b t t 6"6 L)'5 <br />0. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE # ExT' <br />20 �t q5- 4 g I <br />HOME or MAILING ADDRESS <br />a D ILA Sc"r't bn�54- <br />FAX# <br />( ) <br />CITY <l—Lk DY\ <br />STAT ZIP O <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 his a�' tion and hat the work to be performed will and hat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE d FED ALE <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY BUSINESS OWNEfgp� O ERATOR/ AGER ❑ 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the same time it Is provided to me Or <br />my representative. f2AV LAMENT <br />TYPE OF SERVICE REQUESTED: Y7U0(d <br />-,�IIVED <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODe <br />PIE: <br />d <br />Fee Amount: ' S:;)- t10 <br />Amount Paid <br />I S �, <br />Payment Date <br />Payment Type ,e61 t <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />