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SAN JOAQi1INUNTY ENVIRONMENTAL HEALTH <br /> EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIt:E REQUEST# <br /> 5koo 5 <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS <br /> LN <br /> t FACIUTYNAME d�Gpc 1 pr�$IN eF-09ef!7Vy <br /> SITE ADDRESS 2-Z�'Sk0 fJ Dti7STIN c,*v tIPb qua ZD <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> F CITY STATE ZIP <br /> PHONE 91 ExT. APN# LAND USE APPLICATION# ��47 <br /> ( ) oU-+ - o5 o -43 Pry-O'l°�-a�a�. ms' <br /> i PHONE#2 ExT• BOS DISTRICT LOCA 0 CODE <br /> x <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �iBy CLO CHECK If BILLING ADDRESS <br /> I BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 40'} w• n K- s i (zoo) 3�-03� <br /> CITY L-0'L STATE CA 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 ENVIRONMEN'rAL 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 /> eevz-oa (4-1 <br /> APPLICANT'S SIGNATU �p�( /� 10ftP DATE: 14!�5' '�`�� <br /> PROPERTY/BusINESS OWNER❑ ERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 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: (ZC\h L-) 90?-�1NCt +s uF>Siltz�kCtr CeN SWVI'►tV�Pri�ON �Gi��� <br /> COMMENTS: RECEIVED <br /> OCT 0 9 2009 <br /> SAN <br /> TM <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: V L £.l �. EMPLOYEE#: ?J DATE:(4 Q (1 <br /> ASSIGNED TO: 61 NA- EMPLOYEE#: 3 DATE: D L 4 r© <br /> Date Service Completed (if already completed): SERVICE CODE: 3 (5 PIE: <br /> Fee Amoun • �3 F C39 Amount Paid Payment Date <br /> Payment Type i S Invoice# Check# 1 rDtk q S _ k�s.� Received By: <br /> EHD 48-02-025 ` 3 1�$ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />