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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTIiIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ PERATOR <br /> - CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS '5,, ✓ ��U U '-s <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site/Address) <br /> X0C _✓ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'l EXT. APN# 330 -larl LAND USE APPLICATION# <br /> - <br /> i - D3 <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 /> 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 ENVIRONMENTAI.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 ice" I»�_ �w� z1 DATE:' <br /> PROPERTY/BUSINESS OWNER 121r' OPERATOR/NIANAGER ❑ 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 envirommental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL-11i 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: E0 a �+ O .(�` F-T70 PAYMENT <br /> COMMENTS: <br /> OCT 0 5 2009 <br /> $AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HM.TH DEPARTMENT <br /> ACCEPTED BY: ©�L 0 t �-�t- EMPLOYEE#: 3 Z DATE:/d S` Q / <br /> ASSIGNED TO: EMPLOYEE#: 2-0 DATE: IEVs' <br /> Date Service Completed (if already completed): SERVICE CODE: p� P 1 E: (4 <br /> Fee Amount: -5, O O Amount Paid U Payment Date 1 510 <br /> Payment Type V Invoice# Check# Received By: f✓ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />