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_ __ . _ _ _ _ . � � .._,.. �. v....��.. a a aa.......... +a.. i as �.. • •.i a ai. i �1L' 1`1 1 <br />SERVICE REQUEST <br />T f12 n <br />ype o ustness or roperty 1W FACILITY ID # SERVICE REQUEST # <br />]__OWNER i OPERATOR -7 <br />CHECK if BILLING ADDRESS O <br />FACu Y NAME <br />SITE ADDRESS � C <br />Pt,.e;t Number t Direction ' 1 _(� reet Name Cit Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />i .. <br />-"ONE#i ExT• APN # LAND USE APPLICATION # <br />PHONE #TT• BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />•REQUEST ' <br />. CHECK if BILLING ADDRESS D <br />BUSINESS NAME <br />f _ HOME or MAILWG ADDRESS 6/-6 -l.0 <br />j <br />CrfY ��� <br />7 , STATE C A ZIP ` <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />r aclmowledge that all.site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed tome ormy`business as identified on this form <br />I also Certify that I haveprepared this application and that the work to :be performed will be done in accordance with all SAN JoAQUu1 <br />COUNTYY Ordinance Codes, Standards, STATEand FEDERAL la s. <br />UCANT'S SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR I MANAGER 0. AUTHORIZED AGENT <br />- f APPLICANT isnot the BHJ"GPARTY, proof of authorization to sign is require Title <br />AIJTIIORE TION TQ RELEASE' INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above, site address, herebyauthorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />uiformation to the SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />:provided fo iile`or my representative. <br />TYPE OF SERVICE REQUESTED:PAYMENT <br />\ <br />a:OrtN>ENrs:- RECEIVED <br />- --- <br />NOV 2 5 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />166EPTEU B EMPLOYEE ne /A (z-4 DATED/ <br />ASSIGNEDTO: In t/EMPLOYEE <br />#: �.Z— <br />DATE: Z 11 <br />0 <br />e-- <br />ryi <br />Date 5ce Compieted (if acre y completed): <br />SERVICE CODE: <br />Fee Amount: o Amount Paid <br />rJ <br />Payment Date <br />12 S/pq <br />Payment Type <br />Invoice # ` <br />Check # ' I <br />Received By. <br />EHD 48-02-025 <br />_- REVISED 11/17/2003 <br />