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SAN JOAQUIN COUNTF ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( 1 -(A-• A-U0S a 6� <br /> OWNER/OPERATOR J <br /> 1NCHECK If BILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESSIS' _�QIe Pe <br /> Lot (� Street Number Direction <br /> Street Name it Z( Code <br /> HOME Or MAIOG ADDREL$S llf Di rent from Site Address) <br /> t a x V Street Number Street Name <br /> CITY o STATE Ip <br /> h r <br /> PHONE#1 EeT. APN# LAND USE APPLICATION# <br /> Q6?) ?g` 3 !- ze - A- ao z v <br /> PHONE#2 = <br /> BOS DISTRICT LOCATION CODE <br /> ( r0 7945- T It1�l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO �r� ``�, <br /> f�(�.�] � G y1Q,f�,el CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# E>R. <br /> HOME or MAILING ADDRQESS FA <br /> I(# _ S <br /> CITY C <br /> J STATE ZIP <br /> CAI <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 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. <br /> /r�t�9) 1 Q <br /> APPLICANT'S SIGNATURE: (tJ XCt X I,\ DATE: <br /> PROPERTY/BUSINESS OWNER❑ VOPERATORI MANAGER ley OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is riot the B/LUNG PARTY.proof of authorization to sign is required Ttrfe <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: L (lp RECEIVED <br /> COMMENTS: �jY lZ//fi// /�1j�YU tL/ DEC 3 1 2009 <br /> /2c1�27YPtt/l[7^tea I z� I d t <br /> ,41 ie3«ICl 3Q � SAN J:�A.^,CIN 'COUNTY <br /> ENVIRONMENTAL <br /> (16411,J) HEALTH DLPAHTMENT <br /> ACCEPTED BY: EMPLOYEE#: r DATE: I <br /> ASSIGNED TO: PSEMIA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECO ���j PfE; <br /> Fee Amount: Z °' Amount Paid V. O D Payment Date 31 O, <br /> Payment Type Invoice# Check# -519(Q Received By: <br /> '?48-02-025 SR FORM(Golden Rod) <br /> rlSED 11117/2003 <br />