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Facility Name <br />Site Address <br />Street Number <br />StateCity <br />Land Use Application #APN#Ext. <br />110-230-006 <br />Location CodeBOS DistrictExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext. <br />Business Name <br />Home or Mailing Address ) <br />ZipState <br />City <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property <br />7 - - 2^ <br />Type of Service Requested: <br />Comments: <br />Date:Employee #:Accepted By: <br />Assigned to: <br />Fee Amount: <br />Payment Type <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SERVICE REQUEST# <br />STOCKTON <br />City______4633 <br />Street Number <br />PACIFIC AVE <br />Street Name <br />95207 <br />Zip Code <br />Date Service Completed (if already <br />Direction__________________ <br />Home or Mailing Address (if Different from site Address) <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Street Name <br />Zip <br />Phone#1 <br />(209)594-2100 <br />Phone#2 <br />( ) <br />Check if Billing Address^] <br />Check if Billing Address E <br />completed): <br />I Amount <br />Invoice # <br />Phone# <br />J___I <br />Fax# <br />( <br />Type of Business or Property <br />COFFEE SHOP___________________|| <br />Owner I Operator . zn s 1 <br />7-20 7^3 <br />Date: TQ - 23 <br />|P/E: l(/0l <br />Received By: Z //-'J <br />Employee #: <br />| Service Code: 5^3 <br />CijZ) Payment Date <br />check# 16,57^377 I <br />• • • i or business owner, operator or authorized agent of same, <br />7ctaowie'dge to all sZand/or project specific EnZonmental 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 FEDERAL laws. <br />APPLICANT’S SIGNATURE: 2S__ Date: >< <br />Property / Business Owner 0 Operator / Manager Other Authorized Agent _ <br />If Applicant is not the Billing Party, proof of authorization to sign is required rule <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 <br />information to the SAN JOAQUIN County Environmental Health Department as soon as it is available an^|hesame time <br />provided to me or my representative^________________,