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09/26/2008 FRI 16:49 FAX 2094683433 SJC EHD <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />10007/007 <br />Type of Business or property <br />FACILIT"Yj ID # <br />SERVICE REQUEST # <br />J OP OR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: <br />DATE: <br />SITE AQPRSS <br />I =_,,,0 <br />n <br />e U W li, <br />Date Service Completed (if already completed)' <br />' n <br />oy� <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Fee Amount: <br />Street Name <br />CITY <br />ate \\ 2S d g <br />STATE zip <br />PoNE #1 EXT. —TPN* <br />�) X52 �I-�22 <br />Check # L+ PSI <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />t ) <br />808 DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />A <br />CHECK if BILLING ADORES <br />COMMENTS: <br />NOV 2 5 2008 <br />SAN JOAQUIN COUNTY <br />HEALTENVIRONMENTAL PARN <br />11111131Q% KARROM <br />EMPLOYEE #: <br />DATE: <br />_ _ <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specidQ ENVIRONMENTAL Hiw,rt1 DL;I'ARTME.NT hOur'ly Charges associated with this project <br />or activity will be billed tome or my b ness as i ratified on thjs.lorrn. <br />I also certify that I have prepared <br />COUNTY Ordinance Codes, Stand <br />be performed will be done in accordance with all SAN JOAQUIN <br />APPLICANT'S SIGNATURE: DATE: I •�, V <br />PRomauI'Y/Bus NESS OWNER❑ PEIL�TOR/V .F;R ❑ rnEliAiJ'rl[Oltl'/..EDr�GEN'f <br />fAppi t lwNr is not the 13/l_cGVG Plw'), proof c f authorization to sign is rerirrired V TNl e <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 ENVIRONMEN'I'AI, HEAI:rii 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:RE <br />COMMENTS: <br />NOV 2 5 2008 <br />SAN JOAQUIN COUNTY <br />HEALTENVIRONMENTAL PARN <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed)' <br />SERVICE CODE: <br />P i E: <br />Fee Amount: <br />Amount Paid , 5 <br />Payment <br />ate \\ 2S d g <br />Payment Type <br />Invoice # <br />Check # L+ PSI <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />