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SAN JOAQUIP-COUNTY ENVIRONMENT AL'HEALT� DEPARTMENT <br /> SER«CE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO "s <br /> � �� r ' CHECK if BILLING ADDRESS <br /> FACILITY NAME419 <br /> V <br /> SIT DDRESS j �/15`S� Iz �lA t— <br /> Street Number Direction '`�' Street Name city_ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> t EXT. AAPNNj#© r��j G LAND SE APPLICATION 9 <br /> ! PHONE#� ll- %-C. 70' 3 �'f V�—D f W r MJ <br /> } PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> t ( ) <br /> 92. <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> IF-0 G F Ido C- J �i <br /> PHONE# ExT' <br /> BUSINESS NAME 2 0p <br /> HOME or MAILING ADDRESS FAx# V\ <br /> 1 (7 6 n v l(z- rzr ( ) <br /> STATE zIP � <br /> CITY - c..�. <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii DEPARTMENT hourly charges associated with this project or <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 and FEDERAL laws. {\1 <br /> APPLICANT'S SIGNATURE:. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �!C �(i14�_AIL_ <br /> IfAPPLICANT 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 Lt 1LFAG C.► .� ti �+�GIF_ f`� � <br /> COMMENTS: R_�_/ � 7 RECEIVED 7-1-1 �14e-ill <br /> MAR 13 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: D�L v�� ,D_�t EMPLOYEE#: DATE: 31 4 e7 <br /> ASSIGNED TO: O.ns EMPLOYEE#: ��Lp C�s DATE: l3 D <br /> Date Service Completed (if already completed): SERVICE CODE: 3 !� PIE: <br /> ��Q3 <br /> Fee Amount: Amount Paid ` Payment Date 3 <br /> Payment Type Invoice# Check# 11 g S Received By: <br /> EFiD 48-02-025 SR FORM(Golden Rad) <br /> s REVISED 11/17/2003 <br />