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SAN JOAQUI'- BOUNTY ENVIRONMENTAL REALT'- DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME Or MAILING ADDRESS <br />r -i4- wo t+a3 <br />CITY STATE ZIP <br />OWNER/ OPERATOR _ , <br />AM,4G- 1 A '/ <br />. CA <br />( <br />©Lt. �/E f <br />CHECK If BILLING ADDRESS <br />�'/�A%• <br />FACILITY NAME <br />JW <br />DATE: 217 1c) <br />SITE ADDRESS ('0 2-- 710 <br />I <br />t�tM <br />EMPLOYEE#:Zl3' <br />r <br />DATE: ( 24 0 <br />qSZ�� <br />Street Number <br />Direction <br />Street Name <br />Fee Amount: <br />23 0, -0p <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />l/ <br />Invoice # <br />Po -7p q O Street Number <br />Check # <br />Street Name <br />CIN <br />A. <br />STAT1-Grrd <br />CSE <br />ZI�-52-47 <br />PHONE#1 Ex. <br />APN# 060 160 Ot. o <br />LAND USE APPLICATION# <br />1.iv°Q q76 -o66a <br />060 196 O10 <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # ExT. <br />HOME Or MAILING ADDRESS <br />FAx# <br />CITY STATE 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 or <br />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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: a, DATE: <br />PROPERTY/ BUSINESS OWNER RIt OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the BILLING PARn 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 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: 60t- <br />S0.4 �t=��}j ap �E>•'ttl t76(— <br />COMMENTS: <br />PAYMENT <br />RP <br />pp <br />�� f �U�� JUN 2 9 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENT ENT <br />ACCEPTED BY: <br />©Lt. �/E f <br />EMPLOYEE #:032 <br />DATE: 217 1c) <br />ASSIGNED TO: <br />(�G// n �1 'Z _e1 <br />EMPLOYEE#:Zl3' <br />DATE: ( 24 0 <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />5-7 <br />P)E: 3rWZ <br />Fee Amount: <br />23 0, -0p <br />Amount Paid 0?C519 <br />Payment Date <br />Payment Type <br />l/ <br />Invoice # <br />Check # <br />I OeceiveABy: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />