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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CHECK if BILLING ADDRESS 0 <br />Type of BUsj.ness or Property FACILITY 10 #SERVICE REQUEST # <br />5~O(IC077;;- <br />SITE ADDRESS -I V ;Yh e> <br />Street Number Direction I 7....vstreet Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />S~""'~_Street Number <br />CITY STATE ZIP ~ <br />~ <br />Street Name <br />EXT. <br />BOS DISTRICT Y LOC~NCODE75/ <br />LAND USE ApPLICATION # <br />EXT. <br />APPLICANT'S SIGNATURE:X V ~/-:-=(~bh7fo c--= <br />~ <br />~ <br />~ <br />~ <br />~. <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 S <br />COUNTYOrdinance Codes,Standard~,SJfoJE and FED~laws.~, <br />DAT~r-IZ -2.0~~ <br />PROPERTY/BUSINESSOWNERtr "OPERATOR /~AGER 0 OTHER~HORIZED AGENT t2 W tv<...-r ~ <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 above <br />site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUINCOUNTY ENVIRONMENTALHEALTHDEPARTMENTas soon as it is available and at the same time it is provided to me or <br />my representative. <br />CONTRACTOR /SERVICE REQUESTOR <br />k CHECK if BILLING ADDRESS 0 <br />ZIP 9' <br />BILLING ACKN9WLEDGEMENT:T,the undersigned property or business owner,operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTALHEALTH DEPARTMENThourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />COMMENTS: <br />AUG 1 2 2010 <br />TYPE OF SERVICE REQUESTED: <br />.h~..ye-k/~;:;' <br />~:;,y~~:~~.-'d-~c~c ~e-//""")'~~C)9~~__ <br />PAYMENT <br />RECEIVED <br />EMPLOYEE#:55-y <br />EMPLOYEE#: <br />Date Service Completed <br />Fee Amount:-:O?~00 Amount Paid /Q J U\../I Payment Date <br />Payment Type .:/;.a;K Check #/ro <br />EHD 48-02-025 <br />07117108 <br />SR FORM (Golden Rod)