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SAN JOAQUIN &LINTY ENVIRONMENTAL HEALTP*PARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 37-1, L' r L,p ('t <br />I U <br />Type of Business or Property <br />BUSINESS NAME{� ( <br />tV V <br />FACILITY ID # <br />SERVIC R QUEST # <br />HOME or MAILING ADDRESS <br />Ono IbbfiT) <br />FAX # <br />c 6 l '61 <br />CITYR <br />K f! n <br />STATE ZIP <br />SERVICE CODE: <br />OWNER / OPERATOR <br />P I E: <br />Fee Amount: <br />CHECK If BILLING ADDRESS <br />Payment Date p <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />FACILITY NAME 1 <br />SITE ADDRESS 512-1 �) <br />IJ 5 <br />C-041Si 914 n- <br />I <br />1'�-Rcx <br />9 '55-76 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />(M) <br />I25� <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 37-1, L' r L,p ('t <br />I U <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME{� ( <br />tV V <br />ee.rxr* a ooci Nq <br />ENT <br />PAYMENT <br />IVED <br />SEP 12 2008 <br />PHONE # 1,, j /, EXT. <br />( tL I r & <br />HOME or MAILING ADDRESS <br />UAU <br />E §O <br />FAX # <br />c 6 l '61 <br />CITYR <br />K f! n <br />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: 'n L19 DATE: �1 ' 10 (?) <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT'Q u J� anf n�iy Q <br />If APPLICANT is not the BiLmNGPARTY,, proof of authorization to sign is required ""I 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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: V 6T <br />COMMENTS: T—lu L i� �5e�' q b�ecr\I w� <br />t <br />a Emtcy) 5eccndQ <br />ee.rxr* a ooci Nq <br />ENT <br />PAYMENT <br />IVED <br />SEP 12 2008 <br />ACCEPTED By./ -,/EMPLOYEE <br />#: <br />UAU <br />E §O <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 I��r D D <br />Payment Date p <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 z y � :r x 1-774.,7o q? ao') SIRFORM (Golden Rod) <br />REVISED 11/17/2003 <br />