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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTAIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RACE REQUEST# <br /> �rltwl I LO T <br /> OWNE OPERfATOR � Ztz <br /> f - CHECK if BILLING ADDRESS <br /> FACILITY NAME I )n `� -7� /tom A S ^ 'a 1_ „ ^ <br /> SITE AD�S e/ Tl" '�iLr (�' ' L� S't�i�- V/ 1511/ <br /> Street Number Direction Street Name CI Zi Code <br /> HOME orMAILINGADDRESS (If Different from Site Address) <br /> N A- Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 yy� EST APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I�l <br /> TT� CHECK If BILLING ADORE <br /> BUSINESS NAME <br /> C a PHO E# 3 / EXT. <br /> Og GI � <br /> HOME or MAILING ADDRESS �/S1� <br /> CITY1 � p STATE ZIP <br /> v � � Vtl� <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 application and that the work to be performed will be done in accordancwit all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. 4 <br /> APPLICANT'S SIGNATURE: % _J DATES:/ �Zl V6 e1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IL'f (0 0`ia rl a �Ll, <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 /> 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. �1�- <br /> TYPE OF SERVICE REQUESTED: c s-r--- �-t— <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> MAR 2 0 2009 MAR 2 0 2009 <br /> SANJOAQNIN O NTY ENVIRJNMENTHEALTH <br /> ACCEPTED BY: <br /> PE,I�MI <br /> 0 L V6 i ,e ^ MPLOYEE#: /� DATE: <br /> �''T CJ o <br /> ASSIGNED TO: y�( J1 ��� EMPLOYEE#: i(- 3 f DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 4� P i E: Z3 <br /> Fee Amount: V3 i ,5- Amount Paid $3 I S b� Payment Date 3 Zp�a <br /> Payment Type �° Invoice# Check# oZa [7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />