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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Propert FACILITY ID # <br />F4 90 0/5.2k <br />SERVICE REQUEST # <br />.5/rdotcooct--3 ,,i___ <br />OWNER/OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME ,. , . <br />SITE ADDRESS <br />Street Number Direction <br />..........„-: fr. . <br />4..-/efq,ei Street Name 5W5241-011 City <br />:5c21,17/ <br />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 />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR( <br />id <br />CHECK if BILLING ADDRESS Ed' <br />BUSINESS NAME <br />7 .‘ rill 498. <br />fr <br />PHONE # <br />1.7.66A <br />EXT. <br />'9 237 <br />HOME or MAILI pRE <br />74.2 <br />FAX # <br />CITY‘449471 STATE /9 ZIP 93237 <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, ST nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: V . DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, prooXof 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 13. %Y'' it- it? 3 /,C,17-01-t PAYMENT <br />COMMENTS: RECEIVED <br />JUL - 8 2010 <br />SAN JOAQUIN CO_UNTY <br />ENVIRONMEI T <br />HEALTH DEPAIR l mt-l'i <br />ACCEPTED BY: <br />-i2e14141- <br />EMPLOYEE #: (2 p../ 3 DATE: 7/7 / ( 0 <br />ASSIGNED TO: <br />tile"btar- <br />EMPLOYEE #: 6 *14,3 DATE: 7/7/f 6 <br />Date Service Completed (if already completed): SERVICE CODE:,50,1-?_ PIE: --r6 0,1_ <br />Fee Amount: d,.30„0--0 Amount Paid $230., 0 -0 Payment Date 17 ( ql C 0 <br />Payment Type L.../ Invoice # Check # S 3 f t Received By: lot <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003