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SAN JOAQUOPUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property L FACILITY ID# SERVICE REQUEST# <br /> fad �fP'f i.� 3?L SI� 6oseros <br /> OWNER i OPERATOR <br /> A �` n CHECK If BILLING ADDRESS <br /> FACILITY NAME Y l� t' ^ <br /> SITE ADDRESS Il"rt4 �� tl/ <br /> I7� Street Number Direction Street Name `� Cit Zi C-,1 <br /> HOME Or MAILIN ODRESS (If Different from Site Address) -MI eb <br /> Street Number Street Name /� <br /> CITY .�jAJF ZIP(4-3-2—:50 <br /> 32—-XJ <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> F-94) 1 Z-,33 - 3(o& -v-7 <br /> PHONE#1 EXT. BOS DISTRICT — LOCATIOI�CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORnI� ' 1 , <br /> IT✓/ ✓✓t CHECK If BILLING ADDRESS <br /> BUSINESS NAME/�T ."\ ^ �n e y^ C W� , n -c I 1 I /t . PHONE# r IN` EXT, <br /> HOME or MAILING ADORES T�, I�(�t�C�� l '�fI`l�J R.-Y 2- <br /> HOME W <br /> r?.Q Gck L53dr8111 <br /> CITY D\` STATE QA ZIP S�O <br /> BILLINGACKNOWLEDGEMENT: 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, STA nd DERAL I WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT MR <br /> If APPL/CANT is not the BILLING PART P 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 /> provided to me or my representative. n l T <br /> TYPE OF SERVICE REQUESTED: L.(-S7- 1 "A* -Z) F I I 12&ymENT <br /> COMMENTS: RECEIVtu <br /> OCT 18 2009 <br /> SAN 3OAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: O U v.E ,(Ll_ EMPLOYEE#: 03z-f DATE: /6/2-P101 6 �./© <br /> ASSIGNED TO: �� ' ` EMPLOYEE#: 5'&C42— DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 19 P 1 E: ,x,308 <br /> Fee Amount: 3 t�j,V7 C) Amount Paid 5 _ Payment Date I 6 <br /> Payment Type Invoice# Check# s Z Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />