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SAN JOAQUIN COUNTY EN VIROP?MENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �SERVICE REQUEST# <br /> �y 91- � <br /> OWNER/OPERATOR - ^- f <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 111 <br /> SITEADDRESS 4,�, \• „ � � t2U/�D L.0�� �5Z4U <br /> D 50 Slreet Number Direction --Yt�— Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> V ,` Street Number Street Name <br /> CITYI STAT ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> c) X100) &0 -CMZ o <br /> PHONE#2 EXT. BOS DISTRICT %Jabe- LOCATION CODE <br /> ( ) Q( <br /> CONTRACTOR / SERVICE REQUEST R <br /> REQUESTQR <br /> CHECK if BILLING ADDRESS■�,;,.r <br /> BUSINESS NAME PHONE# EXT. <br /> 534 3 <br /> HOME or MAILING ADDRESS FAx# <br /> .30 i�v (-7-o ?) 34_ 5-77 3 <br /> I <br /> CITY J o>\ STATE / l ZIP 5 <br /> BILLING ACKNOWLEDGEMENT:KNOLEDGEMEN`T: 1, the undersigned property or business owner, operator /�' Z 4 <br /> tor 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, STATE and FEDERAL laws. a <br /> APPLICANT'S SIGNATURE: f'!� / DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR�AZAM1AGF,R ❑ OT1fERAUTNOREZEDAGENT9C��(J/L <br /> I If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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/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: S 41 2�iQ�� �Sl t Gam_ C.O N 1-A-A'e-t nI A'-r( O rJ <br /> COMMENTS: //Z 9/-6 HAYMENI <br /> RECEIVED <br /> �E-Q-T�1�� ���., t e <br /> -r-: �.' o JAN 15 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 1 HEALTH DEPARTMENT <br />!I ACCEPTED BY: 0 C- C L/&( 12 n EMPLOYEE#: O'�Z r DATE: 111_5110 <br /> I ASSIGNED TO: O EMPLOYEE#: 1"� l DATE: ! / <br /> y J [ <br /> Date Service Completed (If already completed): SERVICE CODE: 1S` 1 E: <br /> Fee Amount: 3D 00 <br /> Amount Paid *930. DO Payment Date <br />{ Payment Type �� Invoice# Check# Received By! <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11117/2003 <br />