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SAN JOAQUI>'-COUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11 sib?/ <br /> OWNER IOPERATOR .qD/�1 CHECK if BILLING ADDRESS® <br /> FACILITY NAME E'-i IN,g�S <br /> SITE ADDRESSt—i DTT {2-ZJ . p� WIC't7 5 �-ZD <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) P.O, aCrX 1534f <br /> C O T-7f?7NN I2_ t6{7 L Street Number Street Name <br /> CITY LQC.KeN� bl2"D STATE C-4\ ZIP 1 �� <br /> PHONE#1 ExT. APN# LAND USE AP PLICATION# 1 <br /> (2Oq) 3 t911- Co-Z 03 c�v'�k-2gt�-I�}c7 P& -tel'or->I 15"O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR c ,icLC <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> LtJE a�K, CztORo�Y►+�� (2- ) 3tpq'- 0 <br /> HOME or MAILING.ADDRESS FAx# <br /> CITY ` STATE CINP- ZIP 41 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> F 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"C E and FEDERAL.laws. <br /> APPLICANT'S SIGNATLTRE: 44��-44DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG. ❑ 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 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: Priv t E W 301 LSv"�i ftF,lt-\► Iv <br /> COMMENTS: <br /> PAYMENT <br /> P.ECEIV ED <br /> NOV 0 2 2009 <br /> � SAN JOAQt11N GGUNTY <br /> ACCEPTED BY: EMPLOYEE#: DY <br /> rrHo MG <br /> ASSIGNED TO: EMPLOYEE#: C� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f E:� � <br /> Fee Amount: Amount Paid --r> Payment Date 1/'.2- U <br /> Payment Type 4 1111 6k-4js� Invoice# Check# !-'Z Received By:. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />