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SAN JOAQUVa-C OUNTY ENVIRONMENTAL HEALT T EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS® <br /> FACILITY NAME t bD VJ I N tlty <br /> SITE ADDRESS t�?-(.¢� �}\t.t_�IDE D2. l�Dl 9a <br /> Street Number Direction treet N m Ci ZI Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> rj�t'ME Street Number Str Name <br /> CITY STATE ZIP <br /> PHONE#i FXT' APN# LAND USE APPLICATION# <br /> (201) 997-alto 053-11-`f0-019- PN -t 00000-4- <br /> PHONE#2 EXT. BOS DISTRICT 7=7 <br /> CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORYN-JC VJZL—C" CHECK If BILLING ADDRESS <br /> YPHONE# EXT. <br /> BUSINESS NAME LAJC. OINK (TE0t�11RD n�wtEN'T ham- _ zAq <br /> HOME or MAILING ADDRESS Tjtoq- 03�5— <br /> FAX# <br /> tf0-k oAK. ST (�) 3to9 - <br /> CITY V OT?I STATE ZIP 4157 1`F0 <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 projector <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 EDERAL laws. <br /> APPLICANT'S SIGNATILTM DATE: 3IL� ze LO <br /> PROPERT t BUSINESS OWNEKE 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 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 /> F <br /> TYPE OF SERVICE REQUESTED: c\ItCt0 SOIL- SvtTA$I LITy �n1tT'f�-r°•'T� L.a>;t�t''`)G STVD�( <br /> COMMENTS: a 6 -�' lzolie Y/-1,7//p PAYMENT <br /> R6F"L-r Q6T/rLz.2 RECEIVED <br /> Ezr MAR 2 9 2010 <br /> ENVIRONMENT, <br /> ACCEPTED BY: EMPLOYEE#: DATE: !7 <br /> ASSIGNED TO: EMPLOYEEM S DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 525- PIE: D� <br /> Fee Amount: 4'5;1g'v Amount Pald r/D Payment Date -;7- i 20 o <br /> Payment Type Invoice# Check# Receiv By: <br /> SR FORM(G den Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />