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SAN JOAQU.,, a OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />cl tis S` A � Q <br />FACILITY ID # <br />�s�3 <br />SERVICE REQUEST # <br />S� <br />OWNER /OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME > <br />0.k -e- L <br />ACCEPTED BY: <br />SITE ADDRESS <br />Street `Number <br />Direction <br />L `Street Name <br />L����c� l��e. <br />Ciy <br />ND Code— <br />HOME or MAILING ADDRESS (If Different from Site Address) <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 />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />pAYME <br />CHECK If BILLING ADDRESS ED <br />BUSINESS NAME <br />FEg 0 4 2009 <br />SNNO RONMENTAI- T <br />HEALTH DEPAR EN <br />ACCEPTED BY: <br />PHONE# <br />EXT. <br />-'I � • <br />HOME or MAILING ADDRr;ss <br />L96 <br />L����c� l��e. <br />FAX# <br />(-[&) <br />b <br />CITY C, %Q— <br />STATE Ch <br />zip q <br />BILLING ACKNOWLEDGEMENT: 1, 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 />1 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: �t.�.t, v-- U /1J. �L�'� �C��j DATE: <br />PROPERTI/BCSINESSOWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZEDAGENTLCIO�,(�(CL �CGQL� <br />if APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 DEPARTMEN'T' 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: J� wS e r` t Zvi <br />pAYME <br />COMMENTS: <br />FEg 0 4 2009 <br />SNNO RONMENTAI- T <br />HEALTH DEPAR EN <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #:�) / A "� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: r P <br />P 1 E:';�J d <br />Fee Amount: �Sf <br />Amount Paid�5 <br />Paymen Date <br />Z y <br />Payment TypeInvoice <br /># <br />Check # SS <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />