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SAN JOAQUOOUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR W CHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEG <br /> SITE ADDRESS 3�4 o N �ra� �l vd Tr"Cit, <br /> ✓��� <br /> Street Number Direction Street Name 2I Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH <br /> N 1 ExT. APN# LAND USE APPLICATION# <br /> r( ) �� 2--c3t) <br /> PHONE#2 EXT. BOS DISTRICT LOON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRES <br /> PFAx <br /> HONE# Q ExT. <br /> BUSINESS NAME 1 <br /> HOME Or MAILING ADDRESS # 1 <br /> P.O. o'c 19 u 30 o <br /> - <br /> CITY I^ STATE ZIP q'52 <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,StandaA;dsSTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> -v7/ <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. ,/� n <br /> TYPE OF SERVICE REQUESTED: LA,(—-I— AFE / av F( / E- <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> APR - 6 2010 <br /> r ,�/� SAN JOAQUIN COU�N1 Y <br /> ACCEPTED BY: a EMPLOYEE#: t_J�L% DAj 10 <br /> ASSIGNED TO: V4C—/`� 1 EMPLOYEE#: r T Z DATE: (01 1 L) <br /> Date Service Completed (if already completed): SERVICE CODE: / Q g P I <br /> Fee Amount: S/-7_s-v Amount Paid 5`� , S b Payment Date L4 I b p <br /> Payment Type Invoice# Check# Received By: N7r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />