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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> I Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR e <br /> —?—VD 'fl D5�A CHECK if BILLING AODRE55 <br /> .moi '[(� M - <br /> FACILITY NAME <br /> SITE ADDRESS t= ' S3 <br /> Street Number Direction Street Narne citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) eoc>O Pou�sTT0. L-Ar`t� <br /> Street Number Street Name <br /> CITY I L' NSF r4 STATE Zip �S�3Ca <br /> PHONE#1 EXT APN# QYG7— X01/ O e LAND USE APPLICATION# <br /> r Zq9 Q65��'M-o5f t71q/-33o-rk A4-IO-;18 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br />' CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AA i p E CHECK If BILLING ADDRESS <br /> PHONE# EXT <br /> BUSINESS NAME b�L�.aN o /Y1u�P�y Zo 33q-66 f3 <br /> k FAX# <br /> HOME or MAILING ADDRESS A 0 - �Ax <br /> `` I2oq I <br /> CITY 1-00! STATE C4 Zip Qtz¢1 . <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. "r <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 30AQUI'N <br /> COUNTY Ordinance Codes,Standards;STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: J Z -/G <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I A'IANAGER OTHER AUTHORIZED AGENT C] <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Till <br /> e # <br /> AUTHORIZATION TO RELEASE INFORMATION: 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/siteassessment <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: d <br /> COMMENTS: PAYMENT <br /> (�pt' ✓� '� tiZI �( � RECEIVED <br /> DEC 17 2010 <br /> i SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL <br /> TMENT <br /> I ACCEPTED BY: EMPLOYEE#: Z ) DATE: p <br />! ASSIGNED TO: EMPLOYEE#: v DATE: <br /> III' Date Service Completed (if already completed): SERVICE CODE: - P I E: <br /> Fee Amount: Amount Paid Payment Date ( ( ,p <br /> Payment Type Invoice# Check# Received By: <br /> ( d <br /> R <br /> l FORM Gon o ) <br /> EHD 46-02-025 SR . <br /> REVISED 1111712003 <br /> I <br />