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SAN JOAQUF 'OUNTY ENVIRONMENTAL HEALTWEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />` <br />/7rd7 <br />S4 00s7evl <br />OWNER/ OPERATOR <br />PHONE # EXT. <br />3 <br />CHECK If BILLING ADDRESS f <br />_ <br />74 <br />11 !i <br />— <br />HOME or MAILING ADDRESS <br />4� 3 a <br />_i7! <br />sem . <br />D tad x3(7-462 <br />FACILITY NAME <br />T"' 7 <br />Pr <br />SITE ADDRESS <br />/ <br />STDG it-' 10 /U <br />c1 Sa I <br />9 Street Number <br />D' -don <br />2/ /Street <br />Naffle/ <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />—Fe cAn) 010ct y �A c <br />x 1 t t�j <br />Street Number <br />Street Name <br />CITY <br />STATE L &0 1 �_ 4 <br />/ <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(S4-7)��—dcZ� <br />�%�(P--(�2p--CS <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTq- --11 <br />LOCATIO CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />` <br />BUSINESS NAME <br />c <br />PHONE # EXT. <br />3 <br />82 SElLo <br />11 !i <br />— <br />HOME or MAILING ADDRESS <br />4� 3 a <br />_i7! <br />sem . <br />D tad x3(7-462 <br />FAX# <br />) <br />CITY �f <br />Pr <br />ST TE ZIP 9-S-6171 <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: I O <br />PROPERTY / BUSINESS OWNER [1OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENTy �/�/�&.5 Af� c:: L <br />IfAPPLICANT 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 />1.J1UVIU1,;;U LU 1IiG vi itty IVIJ1\.J1 "LaUvb. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS,: <br />3 2009 s►�N �oAaum GOVNN <br />;NMEN�T HEALTH <br />H E�N1TN DF TR MEW <br />ACCEPTitD BY: I r2 EMPLOYEE #: DATE: -7/ tJ /� <br />ASSIGNED TO: it / �i _ ,S EMPLOYEE #: 4f 4, 36 DATE: rT` f/ <br />Date Service Completed (if already completed): SERVICE CODE: 11?k P 1 E: 2we <br />Fee Amount: ` 3 I S��v Amount Paid �I S p -c) Payment Date `7 Li p -7 <br />Payment Type Invoice # Check # 3,If.1?_6 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />awicFn 11/170nm <br />