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----- - -11-. L1l r i1MV1 I IT11W11 2-11, 11G111, 1211 _EYAK11V1ENT <br />SERVICE REQUEST <br />Type of Business or Property ' FACILITY ID # <br />C <br />3.q2_ <br />' OWNER / OPERATOR4, <br />r <br />FACILITY NAME <br />SITE ADDRESS. <br />. SERVIC REQUEST # <br />CHECK if BILLING ADDRESS E] <br />Street r Direction <br />Street Name Ci Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE#1 EXT. APN# <br />LAND USE APPLICATION # <br />( ) 03 i b,(0 ;3( <br />ONE #21 T• BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTO <br />T`O_Qi�;;W�l <br />LHECKifB,1LLINGADJDRESS <br />BUSINESS NAME VV I <br />; i P �� <br />AR <br />'HOME Or MAILING ADDRESS. ( <br />CITY 1 STATE (� ZIP S <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 as 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 la s. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />_ PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑. AUTHORIZED AGENT a <br />IfAPPLICANT is not theBILLINGPARTY proof of authorization to sign is require Title <br />-J vAUT AT.TION 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 ormyrepresentative. <br />TYPE OF SERVICE REQUESTED:. S f <br />C0.MMEtirs: <br />RECEIVED <br />JUN 2 2 2010 <br />SAN JOAQUIN COUNTY <br />ENVOMENT <br />HEALTH DEPARTMENT <br />ACCEPTED BY: d.c VP,. i - <br />EMPLOYEE #: <br />O L.( <br />DATE:6 12 ob <br />0 <br />ASSIGNEDTO: C�� 1 1 <br />EMPLOYEE #: <br />/ L f 2i Z <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: 2-3 U <br />Fee Amount: <br />Amount Paid �` <br />Payment Date <br />n <br />o� 2 V <br />Payment Type <br />Invoice # <br />Check # <br />R ceived y <br />EHD.4&02 025' <br />REVISED 11117/2003 <br />