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SAN JOAQUIrV —OUNTY ENVIRONMENTAL HEALTF ")EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> X/V/ 'W'WrV-� 3 1 3 3 .Si2 U 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS G IF <br /> 11 7U� { N�/L St eef t Number Direction 1 1-`f C Street Name / Cit ' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S D 5 4/'U W 4b1f, Street Number Street Name <br /> CITY — STATE/ � ZIP c� C� 7';? <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# / T <br /> c2vr) 6 3 Ns� 3 / e?— b&0 —L2-.-, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> U > J- - ops v I. 3 <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 /> acknowled,,e 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 Ordirruuce CodeS,St(III&II-dS, STATE and I I)FRAL laws. <br /> APPLICANT'S SIGNATURE: l� �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLIC ANT is not the BILLING PARTY,proof of authorization to siln 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: HAY N11 L IN 1 <br /> RECEIVED <br /> JUL 14 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL- <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ©u�����- EMPLOYEE#: p 3 DATE: - j`! O <br /> ASSIGNED TO: �A-e �� EMPLOYEE#: DATE: �) ��Lc� <br /> Date Service Completed (if already completed): SERVICE CODE: / P f E: Flo z— <br /> Fee Amount: l OS Amount Paid l r9 — Payment Date Y D <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />