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SAN JOAQUIr' BOUNTY ENVIRONMENTAL HEALT'- )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE L/6RE/JQUESTT# <br /> D95 <br /> OWNER I OPERATOR TO 6! ,OTT <br /> TO <br /> U CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SI'TEE ADDRESS �( Co� w/t C-�-o�k n g5za5' <br /> 17Street Nember Direction J Street Nam(Ze v Zip Code <br /> HOME or MAILING�ADDRESS (If �II erent from Site Address) M_ St e <br /> Street Number I(` k'l a e <br /> C TATE ZIPgX,,zO <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# b <br /> ( 9) 17-�f63S- 07_ 2rd-oz <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R.EQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> I ) <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 appl cati n nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST TE 1 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 0 l 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environnlenlaUsite 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: '—Op.J� pn/�=f-f,C-"]""Y4—(^Z� T <br /> COMMENTS: RECEIVED <br /> AUG -9 2010 <br /> SAN <br /> ENVIRONME COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ©Lt�—�c EMPLOYEE#: 0324 DATE: <br /> ASSIGNED TO: ��� -�_,t EMPLOYEE M a,2-1,2, DATE: <br /> Date Service Completed (if already completed): I SERVICECODE: PIE: I�QZ <br /> Fee Amount: TIf z- Amount Paid 'fk l'-a O--0 Payment Date <br /> Payment Type /t ti Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />