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' SAN JOAQRT , COUNTY ENVIRONMENTAL HEALTH 11EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID It <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />: <br />1 �29 n <br />I <br />5KO0to�4CC, r <br />OWNER / OPERATOR <br />(Zog) <br />6 q-10 00 <br />HOME or MAILING ADDRESS <br />DATEDATE: <br />CHECRNBIWN6 ADDRESS <br />dj: <br />x430 We S t mora CJ- <br />PIE: '3&0ZFee <br />FACILITY NAME <br />Ce <br />Amount Paid fp �( <br />CITY SSTATE <br />pelL <br />LP fs ? <br />L <br />SITE ADDRESS <br />t &0 (LMS DIM <br />Received By: <br />S(-v��hor <br />45ZIU <br />//�� <br />"I [reel Number <br />Direction vz' <br />fr'"Name Lt <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE It <br />PHONE #1 E.T. <br />APN # <br />LAND USE APPLICATION # <br />(2"1 - UUO <br />PHONE#2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />( 66A (0 2 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />S R - U t` l(eo( rL' obL%otl�. f JUN 2 7 2011 <br />TN- <br />�� �J F�7Yf SAENvIRONMENDUNTY <br />(W'Y�^"'�-E'f I� P�• HEALTH DEPARTMENT <br />PHONE III <br />EXT. <br />OAR. - cA <br />(a/ <br />(Zog) <br />6 q-10 00 <br />HOME or MAILING ADDRESS <br />DATEDATE: <br />FAX# <br />dj: <br />x430 We S t mora CJ- <br />PIE: '3&0ZFee <br />I 1 <br />Amount Paid fp �( <br />CITY SSTATE <br />,� <br />LP fs ? <br />L <br />I <br />t &0 (LMS DIM <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project speck ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />e�' ity will be billed to me or my business as identified on this form. <br />iCEZ-Q*'ertify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />=ITOrdinance Codes, Standards, STATE and FEDERAL laws. <br />�ACANT'S SIGNATURE:�j�=� DATE: <br />41ZFjTY/BUSINESSOWNER❑ OPERATOR/ MANAGER ❑ OTHER ALTHORIZED AGENT❑ <br />�,. 3.. IfAPPLICAVT is not the B/LLING PARTr proof of authorization to sign is required Title <br />4112-MtORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />on to the SAN JOAQUIN CoUNfY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />p4;;;=d to me or my representative. <br />TYPE OF SERVICE REQUESTED: V <br />NAY FI ED <br />COMMENTS: <br />CLAJ I` C' <br />\ <br />CZJ SDX Cave V-5 <br />S R - U t` l(eo( rL' obL%otl�. f JUN 2 7 2011 <br />TN- <br />�� �J F�7Yf SAENvIRONMENDUNTY <br />(W'Y�^"'�-E'f I� P�• HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: q0-7 j 3 <br />(a/ <br />ASSIGNED TO: <br />EMPLOYEE #: 4121 I <br />DATEDATE: <br />Date Service Completed IN already comple <br />dj: <br />SERVICE CODE: 1-a <br />PIE: '3&0ZFee <br />Amount: � L5r-u <br />Amount Paid fp �( <br />Payment Date <br />�. <br />Payment Type V15A <br />IInvoice # <br />I <br />t &0 (LMS DIM <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />