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W If <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />ExT. <br />CIA _ <br />SERVICE REQUEST # <br />FAX # <br />` — 300 <br />3 2,&' y <br />C <br />c 33�- <br />OWNER /OPERATOR <br />30CI1 11der <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ffi I- {i' <br />SITE ADDRESS /1 } �(� <br />Lion <br />- <br />0(_t L/ <br />Cf <br />�/Lr7ber <br />' <br />•C`odev <br />DATE: cc—to <br />ASSIGNED <br />ASSIGNED TO: <br />Street Name <br />Cit <br />DATE: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: ( �� <br />Street Number <br />Fee Amount: <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />Check # l <br />Received By: <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR w `, 11 /ham Ass a4zer r CHECK If BILLING ADDRESSER <br />BUSINESS NAMEPHONE# <br />ExT. <br />CIA _ <br />HOME Or MAILING ADDRESS <br />Fb Xc <br />FAX # <br />` — 300 <br />CITY STATE vfZIP 52/ <br />C <br />BILLING ACKNOWLEDGEMENT: 1, 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar ATE and aws. <br />APPLICANT'S SIGNATURE: , DATE: 5/ Kt <br />O <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT R kh0 . k ILm'/ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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 />infonnation 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: <br />(7— PAYMENT <br />COMMENTS: <br />HECEIVED <br />MAY 18 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />0(_t L/ <br />EMPLOYEE#: lJ 3 <br />DATE: cc—to <br />ASSIGNED <br />ASSIGNED TO: <br />w o &) 6— <br />EMPLOYEE #: 4 L09 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( �� <br />PIE: <br />Fee Amount: <br />3 �S <br />Amount Paid 3 s1 <br />Payment Date ) <br />Payment Type <br />Invoice # <br />Check # l <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�1� <br />