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! j <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O�f <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS C7. <br /> t e a Gt. <br /> FACILITY NAME �{ <br /> SITE Aj DRE55�WjOS E Flow— P r�C. R WA <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /���� �� <br /> ZryQ c / 1 <br /> �{ I [r i� b 0 Street Number Street Name <br /> STATE Zip <br /> ciTv S' D�rl C SZa-J' <br /> PHONE#t ExT- APN# LAND USE APPLICATION# <br /> (?&J ) 4-7Z, -7-700 v&6 _d-7o -l(> P.4- xe A li <br /> PHONE#2EX <br /> T BOS DISTRICT LOCATION CODE <br /> } <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR�} CHECK If BILLING ADDRESS <br /> BUSINESS NAMEY4•µ•m_ !¢ iJ,�' 1 '` PHONE# Ex <br /> A <br /> o V h 3 <br /> HOME or MAILING ADDR S FAx# <br /> CITY STATEC ZIPZZdi <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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,S T and FERE S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> —47 - /U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I ANA ❑ 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time if Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C1 <br /> ,41A-7 7 NAI <br /> COMMENTS: eft p PAYMENT <br /> RECEIVED <br /> yZ1r7�27 P�e���cl�> � <br /> JUL 0 7 2010_ . <br /> - <br /> SAN JOAQUIN COUNTY,`: • <br /> ACCEPTED BY: EMPLOYEE M j} H ffky 1 DEPART ENT <br /> ASSIGNED TO: EMPLOYEE#: 5 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -;,2 ! P 1 E: ' <br /> Fee Amount: 2�{)�,' Amount Paid 4+213-1-0 Payment Date 2-0 l <br /> Payment Type G _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(GoI en Rod) <br /> REVISED 1 111 712 003 <br />