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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTIWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />u <br />FACILITY ID # <br />3 `t 5 - <br />SERVICE REQUEST # <br />OWNER / <br />OWNER/ OPERATOR <br />BUSINESS NAME - <br />CHECK If BILLING ADDRESS <br />FACILITY NAME 3A Nmr I� <br />W lA.tl 6�•( <br />PHONE �' EXT, <br />s p 0 7 2010 <br />SITE,<1DATIS-) <br />C/a LN� ��"ffJJ Street Number <br />Direction <br />Ali <br />tree Name 9R <br />o <br />rnPo <br />Ci <br />R5aa6 <br />Zi Code <br />HOME Or MAILING ADDRESS (If Pifferent <br />t from Site Address) <br />Street Number <br />DATE: 7//L <br />_ <br />Street Name <br />CITY <br />EMPLOYEE #: /q -Z2_ <br />STATE ZIP <br />PHONE#'I I — <br />Y/f1ogll ) <br />APN # <br />SERVICE CODE: (Cr� <br />LAND USE APPLICATION # <br />PHON ilz �/� �T• <br />( ) 3����J`l�� �r <br />Fee Amount: f 3 &&.,,-d <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR- <br />- <br />' <br />- - CHECK If BILLING ADDRESS® <br />/ <br />ma cto <br />BUSINESS NAME - <br />REC'E <br />ll'' <br />PHONE �' EXT, <br />s p 0 7 2010 <br />r <br />V <br />( , <br />HOME Or MAILING ADDRESS_ <br />o <br />FAX# (� <br />( f) _ ( <br />CITY N604STATE <br />ZIP rp <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 or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards T TE and FEDERAL la <br />APPLICANT'S SIGNATURE: % / U /6k—'/—DATE: <br />DATE: / //��I <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT Q(la <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required UP Title 61 <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. AA /V 6fii?F—�A t <br />TYPE OF SERVICE REQUESTED: GtS % <br />ENT <br />COMMENTS: <br />REC'E <br />s p 0 7 2010 <br />S"'S JOAQUIN COUNTY <br />��{ DEPAPTI'AEN <br />ACCEPTED BY: O L t y <br />EMPLOYEE #: 03 7-1 <br />DATE: 7//L <br />ASSIGNEDTO: �' yG .� f(7— <br />EMPLOYEE #: /q -Z2_ <br />DATE: 417 h L <br />Date Service Completed (if already completed): <br />SERVICE CODE: (Cr� <br />PIE: �O �o <br />Fee Amount: f 3 &&.,,-d <br />I Amount Paid <br />b _ <br />Payment Date <br />o1 ✓� ( p <br />Payment Type �4,C-,.XV4` I <br />Invoice # <br />Check # k Q14 — -34 S. n <br />Received By: <br />- p k DO <br />EHD 48-02-025 D� SIR FORM (Golden Rod)' <br />REVISED 11/17/2003 �a <br />