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--<—, --VV AA - L1Nrinvl"irizlNlALrzllaL1t11J1�YAKIINI ;N--r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPTOR <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> t�� I <br /> SITE ADDRESS <br /> Stree Number Direction Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY Street Name <br /> STATE Zip <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> PHONE#T Exr. BOS DISTRICT LOCATION CODE <br /> 29 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME P NE# <br /> HOME Or MAILING ADDRESS �t FAX# <br /> ( � 14t01 -- <br /> CITY STATE ZIP <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 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 laws. <br /> APPLICANT'S SIGNATURE: DATE• 1 (� r)C <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER E01, THER AUTHORIZED AGEN`%�—�•p �11l C 4 <br /> IfAPPL7CANT is not the B=NGPAR77 proof of authorization to sign is required Tire <br /> AUTIiORIZATION 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 environmentaYsite 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. <br /> TYPE OF SERVICE REQUESTED: LA- i'1- l T PAYMENT <br /> - - CommENrs: <br /> MAR 2 0 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DLpARTMENT <br /> ACCEPTED BY: Q L ( VF—, t,84 EMPLOYEE#: C) _ DATE: 3 ZD <br /> ASSIGNED T0: <br /> j EMPLOYEE#: 51 L(2— DATE: 3 ZO 105 <br /> Date Service Completed (if alrea y completed): SERVICE CODE: C c� P i E: Z3 Q <br /> Fee Amount: Amount Paid ?v' Payment Date 3 <br /> Payment Type Invoice# Check# <br /> �3 9�� Received By: <br /> EHD 48-02-025 .SRFQfIVI jGDidn Rod); <br /> REVISED 11/17/2003 <br />