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SAN JOAQL -"OUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />7/ <br />SERVICE REQUEST # <br />wp 2's-/ <br />COMMENTS: <br />4 <br />RECEIVED <br />MAY 1 1 2009 <br />OWNER/ OPERATOR <br />mi -J <br />� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME r rE <br />SITE ADDRESS -10i <br />E <br />C" Re -�� <br />l � <br />VI ny <br />STOC1EI\( <br />;y <br />i ZI�Q <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) <br />Fee Amount: IS.r <br />Amount Paid �i S, _ <br />Payment <br />to 5 t' 0 9 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #'1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS EJ <br />��l-i CSU <br />BUSINESS NAME PHONE of --jam' <br />C( ni Ina O ( ) l <br />HOME or MAILING ADDRESP FAX # <br />CITY STATE ZIP qc <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or all LIIUUIZVU abCUL Ul 3-Alllu, <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 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:Ike DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 6CPf Ey 1,:N1n V 6 <br />If APPLICANT 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 />- a -A +- <br />EHD 48-02-025 SR 1 0RM (Golden -Rod) <br />REVISED 11/17/2003 <br />TYPE OF SERVICE REQUESTED:PAYM/ <br />COMMENTS: <br />RECEIVED <br />MAY 1 1 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: If <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: IS.r <br />Amount Paid �i S, _ <br />Payment <br />to 5 t' 0 9 <br />Payment Type <br />Invoice # <br />Check # q O <br />Received By: <br />EHD 48-02-025 SR 1 0RM (Golden -Rod) <br />REVISED 11/17/2003 <br />