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SAN JOAQL BOUNTY ENVIRONMENTAL HEALT. ,PARTMENT <br />SERVICE REQUEST <br />of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />/ ` /C'f <br />N <br />SERVICE REQUEST # <br />Z;w'Type <br />��C�,c <br />� ���o ��`� <br />CITYSTATE <br />0 �R3 5 <br />OWNER / OPERAT R <br />EMPLOYEE #: �7 V <br />CHECK <br />Date Service Completed (if already completed): <br />--[Amount <br />SERVICE CODE: / <br />If BILLING ADDRESS <br />FACILITY NAME <br />Fee Amount: <br />Paid ('= <br />SITE ADDRESS <br />Payment Type <br />S <br />/til• <br />IVIA <br />rTEC� <br />1 <br />1 Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME 0 MAILING ADDRESS (If Different from <br />Site Address) <br />A( <br />Street Number <br />Street Name <br />CITY SIA <br />STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />[�MONE2ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />/ ` /C'f <br />N <br />PHONE # 9N-15_3 7 ExT. <br />HOME or MAILINGADDRESS <br />F10K v78/ <br />FAX # <br />F ,) 94'- 7 <br />CITYSTATE <br />ZIP <br />C,4 9!576 3 <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 <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, TATE and FEDE t* laws. <br />APPLICANT'S SIGNATURE: DATE: 0?/17%2-0/a <br />PROPERTY/ BUSINESS OWNER❑ OPE TOR / MANAGER ❑ OTHER AUTHORIZED AGENT l j�Q/lt <br />IfAPPLICANT 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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:: <br />COMMENTS: r 0 n— 0rfP 6)i/- "/qvD n <br />� 4%�i �/�f 77ary 7� 1;'16W � 7z��i�vy �/siert <br />Q� <br />R p <br />FEB 17 2010 <br />SAN JOAQUIN COUNTY <br />ACCEPTED B <br />EMPLOYEE #: <br />DA":-:v <br />A §/TENT <br />CC// <br />ASSIGNED TO: uM t <br />EMPLOYEE #: �7 V <br />DATE: <br />Date Service Completed (if already completed): <br />--[Amount <br />SERVICE CODE: / <br />P 1 E: <br />Fee Amount: <br />Paid ('= <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 49/57 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />