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SAN JOAQL,.+ COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A IV Tsioc S LLI <br /> O_WWER OPERATOR <br /> CHECK 11 BILLING ADDRESS <br /> FAY NAME <br /> T <br /> Q <br /> SITE ADDRESS <br /> Street Number Dirac ion Stree[Name Ci 21 CoEe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ev. ARM# r-� f� Q LANDUSE APPLICATION# <br /> ( ) 0 Zn1 •• ` f 0—J t <br /> PHONE#2 En. BOS DISTRICT � LOCATION DE <br /> ( ) C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUIESTOR1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME L/V J,/,_ ILLLCCW/�+N ' PHONE# E.T, <br /> /CC/' 1 �✓ <br /> HOME or MAILING ADDRESS N FAx# <br /> ( ) <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 <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 E and FEDERA ws. <br /> / <br /> APPLICANT'S SIGNATUR DATE; [7 <br /> PROPERTY/BHSfNESS OWNER O TOP A +P OTHER AUTHORIZED AGENT <br /> IfAaruca vT is not the BILLING Pa pr f of authorization to sign is requir d Title <br /> AUTHORIZATION TO RELEASE 1NFORMAT : 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 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: uST P/ IP r ,J /� = 104 f/IIP pAYM D <br /> COMMENTS: <br /> DEC - 1 2009 <br /> S�ENVIRON"Al Ertl <br /> HF�TM DEPARTM <br /> ACCEPTED BY: QLIv�tfJ aQ, EMPLOYEE p3 DATE: !Z ' 02 <br /> ASSIGNED TO: AG��•�S`- ` EMPLOYEE#: r_'36 DATE: ! t Q <br /> I <br /> Date Service Completed (if already completed): SERVICE CODE: b P I E: �30� <br /> Fee Amount: S-;Oo Amount Paid 3Li 5 Payment Date <br /> Payment Type Invoice# Check# g O \ Received By: Wcr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />