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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/05/ <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />01:v(-- Pctv K Aph <br />SITE ADDRESS i ,76, <br />Street Number Direction VoRg Galt /V <br />Street Name <br />/114/43e_cYt. <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(&Ø ) d39. MO <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BUS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR A _ 1 <br />t. USTOrl P0414^ fge AJ eh — eb.1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 3/4 <br />P°"1 <br />PHONE # Exi <br />(G/of ) s-3 1- <br />HOME or MAILING ADDRESS <br />'''t9") , 7vais4vsex tied FAx # <br />(do ) 537- (0.5-Yi <br />cny ceieti. STATE c . rf . ZIP 9.S..3o 2 <br />il--------- DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AG ENT412. 1/45', e4 cie vvee <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 <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: V6-/3 PAYMENT <br />COMMENTS: RECEIVED <br />JUL 1 8 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED By:( ,.,..... •C"--- EMPLOYEE #: 9 075 3 DATE: 7 s.... / <br />ASSIGNED TO: V , )--901"-Lcv -v.',A_ EMPLOYEE #: 60,2 / 13 DATE: <br />Date Service Completed (if already compleik): SERVICE CODE: P I E: 3 c' <br />Fee Amount: .../:-.2,r2:--7-101,4"—Amount Paid Z96 ci ll Payment Date 7/ 1 p-- / ( <br />Payment Type Invoice # Check # 1307 I Received y: a <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 JoAQurtv <br />COUNTY Ordinance Codes, Standards, A and FEDERA aws./ <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)