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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQ ESj.�F <br /> OWNER I OPERATOR I Q(/ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS l�'"`�7 �o(S 4, •7—�,E� SLS Cy, o�/'�, �S�p Trp <br /> streA Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (IfD' erent from Site Address) <br /> 4� Street Number Slreel Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# 'ZOO LAND USE,{lP/PLICATION# <br /> Z 7i/ <br /> ( ) T —O rt f <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# E.. <br /> HOME or MAILING ADDRESS n FAX# <br /> ( ) <br /> CITY ( • STATE ZIP .l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agenk 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. � <br /> APPLICANT'S SIGNATURE: e_ 'e / j�A :_ l�(L� DATE: Z� Z q7 01 <br /> PROPERTY/BUSINESS OWNER El OPE tTOR/MANAaarA( L_I OTHER AUTHORIZED AGENT`T+ ��` �__ k Y� <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title I <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 t0 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. 90 11- S cG: L r 0' <br /> YM <br /> TYPE OF SERVICE REQUESTED: PA ivF:D <br /> COMMEMS: 2 Zy 5 �.�/�W-� �>e+qJ <br /> ;�- �/v� Mph 2 3 2009 <br /> SMJOPQUIN COUNTY <br /> ENVIRONMENT� T <br /> 1lM HEALTH DEPARTMEN <br /> �.� <br /> ACCEPTED BY: C)L--I V 4E I �./J A�i EMPLOYEE#: O DATE: L3 Q <br /> ASSIGNED TO: I�J�T EMPLOYEE#:6 tes DATE: .; O <br /> Date Service Completed (If (ready oomplBled): SERVICE CODE: C. PIE: 2Co <br /> Fee Amount: �t,D,a:b Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />