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SAN JOAQU OUNTY ENVIRONMENTAL HEALTHPARTMENT <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME , ® ®�A �/ y ` <br />ACCEPTED BY: <br />y� �/p ® �j Exr' <br />OWNER / OPERATOR ® _ ,r / _ _ E� <br />S- /P ✓—'(f�-QG�/� G (/N/�/ � L!/,QL�C �./(,%�Ie3 �f°%ZIA %' iC ,�/�% SKJIf BILL 0 ADDRESS® <br />FACILITYNAMECy <br />6 ® ° l <br />STATE <br />CITY /�;W 1 <br />SITE ADDRESS T <br />/(/ / <br />�/�//G jE.'' 4 yL/�� <br />® <br />® <br />SERVICE CODE: <br />P I E: <br />Street Numrber <br />Direction <br />Street Name <br />Invoice # <br />CityZip <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) / /® `G" <br />1 t✓ G 76;hl <br />t/e-� <br />Street Number <br />Street Name <br />CITY .ry /� ® <br />/` <br />STATE c Zip <br />Q �® <br />PHONE #1vG <br />EXT. <br />00) / F <br />APN # ff11® <br />0,9 <br />LAND USE APPLICATION # <br />PHONE #1 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR <br />C V ` <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME , ® ®�A �/ y ` <br />ACCEPTED BY: <br />y� �/p ® �j Exr' <br />HOME Or MAILING ADDRESSq �/ <br />1 14`11- 0 If ✓ <br />(A� 1 <br />6 ® ° l <br />STATE <br />CITY /�;W 1 <br />a f- <br />ZIP / d 12-0 <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, STATE and FEDE aws. <br />APPLICANT'S SIGNATURE:ZA6�"& DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTfl <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is requireM Titl a s -OZ/, * <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 />TYPE OF SERVICE REQUESTED: <br />® p <br />COMMENTS: //�I L C /N FJ /��G /` i✓% �/ /���C % ` <br />/�Y.i/ILC / /i/�" <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />