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SAN JOAQUINWUNTY ENVIRONMENTAL HEALTImok-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a:a, [ &tq Soo X997 7 <br /> OWNER/OPERATOR <br /> L � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> G (may <br /> SITE ADDRESSLJC:(I <br /> `f <br /> Street Number �l7irection Name -S 71- Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# (y LAND USE APPLICATION# <br /> ( r ) DY S -- 2-91D-,->-9' <br /> PHONE#2 EXT. BOS DISTRICT ' / LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ad?) <br /> CITY STATE ZIP <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 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: DATE: <br /> PROPERTY/BUSINESS OWNER���r OPERATOR/MANAGER O AUTHORIZED AGENT❑ (/w/-,.or <br /> If APPLICANT is not the BILLING PARTY proof of au tzation 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. FOp 0 CO nJ Sc-( C-17---77 O <br /> �E <br /> TYPE OF SERVICE REQUESTED: Pf�Y I t <br /> COMMENTS: <br /> MAY -t 2010 <br /> SNENV RONMEWAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M �a,9? DATE: 4919" <br /> 1/f/m <br /> ASSIGNED TO: EMPLOYEE Q11;14 3 DATE: S S IO <br /> Date Service Completed (if already completed): SERVICE CODE: 0 <br /> Fee Amount: Amount Paid _ Payment Date 5 s I O <br /> Payment Type Invoice# Check# 5 l 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />