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IF <br />SAN JOAQUIN COUNTY ENVIRONMF,NTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/1 <br />FACILITYJP <br />SERVICE REQUEST # <br />BUSINESS NAME <br />PHONE # EXT. <br />36 J -- <br />OWNER/ OPERATOR <br />FAX # <br />( Z/,/,)'��s- <br />CITY / _A� <br />yz,,�\ / 1 r <br />t� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />!) <br />HEALTH DEPARTMENT <br />I t ` 4l` <br />EMPLOYEE #: <br />�G/Goy" I Lid <br />9 � t 0 <br />V J Street Number <br />Direction <br />/Z T <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Amount Paid1 <br />Payment Date <br />Street Number <br />Invoice # <br />Street Name <br />CIN <br />Received By:t <br />STATE ZIP <br />PHONE #1 EXT.APN <br /># <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />1 <br />BOS DISTRICT <br />0 �;- <br />LOCAT N CODE <br />[ <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />/1 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />36 J -- <br />HOME or MAILING ADDRESS <br />//0 6/ G,v 37-39 <br />FAX # <br />( Z/,/,)'��s- <br />CITY / _A� <br />STATE ZIP 9SzC(G <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH Di:PARTMEN'r 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 JOAQIIIN <br />COI 0I-dh7Qi7Cc' <'nc/es,.iYandurc/s, STATI; and FI:DI:ItAI, laws. <br />APPLICANT'S SIGNAIAI ��� <br />PROPP;I1'n'/I3usINl•ssOhvNl•a10 OI'I•'RA-I'OR/MANA(;E.R ❑ 0'ruI-A1AIf"fu0RizEi) Aci:NrM51 �/Z1'4i1r,"f AT, IA -1-711- <br />ff. IPPi.I( ,INT is t7ol the Hil.l,ING 1),IR/T. proof (f authorization to sign is required Title <br />AU1410R1LATION 7'0 RELEASE INFORMA'PION: When applicable, 1, 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 env iroll nlcntal/site assessment <br />illfOrmatiOn to the SAN ,IOAQLJIN 0)(INIY I;NVIRONMENfAI. HI{Al,'I'll DF,I'AR'I'MEN I' as soon as it is available and at the same time it is <br />provided to ine or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />/1 <br />COMMENTS: <br />JUL 6 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTE BY: ,rye) <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: Y r �G <br />EMPLOYEE #: ��J h <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />O <br />Fee Amount: <br />Amount Paid1 <br />Payment Date <br />Payment Type l� <br />Invoice # <br />Check #l{ <br />l <br />Received By:t <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />GK <br />