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SAN JOAQUPCOUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />'CI_V0 JgAo-ICL <br />FACILITY ID # <br />jA00030%9 <br />PAYMENT <br />SERVICE REQUEST # <br />�����707i <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />� yr !/ vl''fjr• p Q�"lq-sem <br />a <br />SITE ADDRESS'24q}C,1Ge!K3 <br />Street Number <br />I Direction <br />` Street Name <br />Cit <br />77 <br />Zip Code <br />HOME[Q�r MAILING ADDRESS (If Different from Site Address) <br />f • 0• }L P23-20 Street Number <br />Street Name <br />CITY <br />PLEA�f�f•1T 1yL.L., <br />�J Zt /3/39 i /r/i ItOY/q� <br />STATE ZIP <br />2 Z, <br />PHONE #1 ET• <br />(qls) 630 -ROW <br />DATE: /,q// <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT. <br />BOS DISTRII <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />cw i u CHECK If BILLING ADDRESSI�..I <br />BUSINESS NAME PHONE# EXT' <br />HOME or MA G ADDRESS / FAx# <br />(72S) 1080 <br />CITY � STATE 64 ZIP <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 <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 ERA aws. <br />APPLICANT'S SIGNATURE: DATE: G' 2o13 <br />PROPERTY/ BUSINESS OWNER❑ O RATOR / ANAGER OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLTNG 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 />EHD 48-02-025 /��j j ��d��✓� b� g/� Gdz,CQ �1V � c�Qa�VS �o' r SR FORM (Golden Rod) <br />REVISED 11/17/2003 �7 - / y -tr/w <br />PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: (� '` ( � r /� <br />3i 7s <br />� yr !/ vl''fjr• p Q�"lq-sem <br />a <br />,� <br />/ <br />APR 302013 <br />SAN JOAQUIN COUNTY <br />WALTH EPAR MENT <br />�� <br />ACCEPTED BY:3 <br />/I/!f/�t� N <br />�J Zt /3/39 i /r/i ItOY/q� <br />EMPLOYEE #: yff <br />DATE: /,q// <br />ASSIGNED TO: � � <br />�u /3 <br />EMPLOYEE #: 11,6' g a <br />DATE: ///Z -7//3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />3 ,' <br />P / E: 41,410 .7 <br />Fee Amount: 3'7 <br />Amount Paid <br />- <br />Payment <br />Date 47,Bl-3 <br />Payment Type <br />Invoice # <br />Check # / 4/ <br />Received By: i` <br />EHD 48-02-025 /��j j ��d��✓� b� g/� Gdz,CQ �1V � c�Qa�VS �o' r SR FORM (Golden Rod) <br />REVISED 11/17/2003 �7 - / y -tr/w <br />