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05!'22/2009 14: 43 6613933523 CHUCK HILL PAGE 02/17 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH.DE,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> ,f�P—rV 1 Ge ���d _ D v� <br /> OWNER/OPERATOR CHECK if BILLING ADD S <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Nu bar Diractinn �✓ tran Demo CI zip cpdo <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strnat Number 9 a n <br /> CITY STATE zip <br /> PWON01 <br /> Exr. APN# LAND USE APPLICATION# <br /> (e2G9)"7e'6K 9S/ <br /> PHONE 92 E:xr, BOS DISTRICT —A LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` /� CHECK If BILUNG_AbDRF!�g❑ <br /> BUSINESS NAME h / / PwgN�E#Q O/ F"T' <br /> tGzA C 6 � 7 D <br /> HamE or MAIUNo ADDRESS <br /> STATE zip <br /> CITY J�,n 44 JC, cS <br /> BILLI'NGACKNOWLEDG1EM_'NCN 11, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project speCific ENVIRONMENTAL HEALTi-T 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 1 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 <br /> laws. c� <br /> APPLICANT'S SIGNATURE: DATE: yp `y,� <br /> PROPERTY/BUSINrssOWNER❑ OPF.R.�'1'OR/-VTAVAGrR ❑ OTHTR,kMI0RIZEDAGTNT❑(no�rjh t'ice rn�f <br /> If APPLICANT is not the BILL1,,NG PARTY,proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASY6 INFORMATION: When applicable, I,the owner or operntor of the property located it the <br /> above site address, hereby authorize the release of any and all resuits, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COtTNTY ENVTRONMENTAT,HEALTH DBP.ARTMENT As soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: pr �E�vT <br /> COMMENTS: r T L <br /> SA ENo�,QUIN <br /> ONMENF NY <br /> HEAL-N DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Compi ted (if already completed): SERVICE Dora; P l E: b <br /> Fee Amount: Amount Paid 3 1 5 _ Paym t Dat® S 2 2—p 9 <br /> Payment Type `� �o�- Invoice# Check p 0 2 313 Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />