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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> " ;/ 1,ki C-lt \ <br /> OWNOPERATORit <br /> Q, CHECK if BILLING ADDRESS E] <br /> FACT v A E I <br /> k \ <br /> SITE ADDRESS <br /> Street Number i lion � tree NarRe C� Zi Cotle <br /> HO Dr MAILING ADDR S (If Different from Site Address) <br /> Street Number Street Nam. <br /> CIT/ STATE ZIP <br /> PHONE#I Ev� APN# LANDy�EAPPLICATION# <br /> ( ) os I - I zo -3 b ;Y/ - ©&-c82 CSy4 <br /> PHONE#2 EXT. BIDS DISTRICT LOCA OOE <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUESTOR <br /> 1 CHECK N BILLING ADDRESS <br /> BUS NE✓NANlf: —1PHONE i-GS ^Z \ EzJA <br /> HO A/F„��[,J�IAILINGADDR SS Fy(# <br /> fA" v T <br /> CITYSTATE IP <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. <br /> I also certify that I have prepared this appiica:pVi9d that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards and FEDE aws. <br /> APPLICANT'S SIGNATURE: DATE,.:, <br /> PROPERTY/BUSINESS OWNER❑ O TOR/MANAGER ❑ OTHER AUTHORIZED AGENT I(d' <br /> IfAPPL/CANT is not 1 e B/LL NG PARTY proof of authorization to sign i5 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: /U LTV-4-T-e LID A-D r/V %D- COIL S LLL'1-11-B 1 u y� <br /> COMMENTS: ,i//T <br /> PAY MEN v <br /> RECEIVED <br /> MAY 12 2009 <br /> ACCEPTED BY: LL v -L EMPLOYEE#: 0-32-1 <br /> : ©3-i J 14 EhIVIR t�AES(i {� f Q <br /> ASSIGNED TO: -1�Q CN^. EMPLOYEE#: �3`& DATE::NICrvPI C O <br /> Date Service Completed (if already completed): SERVICE CODE: ,S`�� P/E. Z <br /> Fee Amount: S�' Amount Paid Payment Date <br /> Payment Type Invoice# Check#:'- F(eceived By:/�'- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />