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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY lD# SERVICE REQUEST# <br /> o b� <br /> OVMER/OPERATOR �j� <br /> - y lzao poDE CHECK if BILLING ADDRESS <br /> FAc um NAME <br /> WE ADDRESS "24 f W24 4'#e+6 <br /> xm 46-W <br /> Street Number Direction r '— 24"Street NAA *0 Ci Zip Code <br /> HOME Or MAILING ADDRESS (I!Different from Site Address) �I!, pp�,9rA- 44 rd C <br /> Street Number I' Street Name <br /> CITY STATE 4�4 ZIP 15- <br /> Z 3�+ <br /> L�nrDs� <br /> E%T. APN 0 LAND USE APPLICATION# <br /> eO7- Wo j 047- -or 3 =v9'/-J%0-0 <br /> PRONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORM I M <br /> CHECK if BILLING ADDRESS D <br /> BUSINESS NAME bI LLOM t /G1 Vndt PHONE# - Ex7. <br /> HoME or MAILING ADDRESS P.O.d. /30�,J 21 S�0 FAx# <br /> (sol ) (> <br /> CITY Lal}i STATE z,P q Z y <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. I <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 EEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BusINESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: 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: <br /> COMMENTS: p/l3�sc� l��f 1 C'� PAYMENT <br /> 1 RECEIVED <br /> ���7 �✓��� �� �-,.* AUG 2 0 <br /> 2010 <br /> SAN JOAQUIN COUNTY <br /> `CyT� ENVIftONA1F1�TA1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: I PIE: t) <br /> Fee Amount: Amount Paid Payment Date Za { <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Gold,Rod) <br /> REVISED 14117/2003 <br />