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SAN JOAQUIN &LINTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME Or MAILING ADDRESS � �\ .� � <br />(,/ <br />FAx # <br />CITY <br />11 STA ZIP <br />OWNR PE R <br />CHECK if BILLING ADDRESS <br />f <br />FACILITY NAMEVAA Mew P, <br />ACCEPTED BY: <br />SITE ADD�RE/S <br />EMPLOYEE #: <br />�// <br />' <br />C �� <br />ASSIGNED TO: „A / i <br />�/ l <br />EMPLOYEE #: <br />J0 Street Number <br />Direction <br />N.,, _ <br />`�1 Ci —" <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />� y%� L��tf- <br />Street Number <br />P/ E: 23001 <br />`Suet <br />CITY� � ,jam, <br />$ T ZIP <br />PHONE #1 EXT. <br />l l '2-&(o .— 7 5 Z <br />/ �J <br />APN # <br />LAND USE APPLICATION # <br />PHJO�N'E"#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO! ``i _ <br />lG �Y� CHECK if BILLING ADDRESS <br />BUSINESS NAME` C <br />ie� v1bh �c1 <br />PHO # EXT. <br />��s0 <br />HOME Or MAILING ADDRESS � �\ .� � <br />(,/ <br />FAx # <br />CITY <br />11 STA 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 <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 t�be rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: "" DATE; Z 710 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER [3OTHER AUTHORIZED AGENT ISI <br />IfAPPL/CANT 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. <br />TYPE OF SERVICE REQUESTED: <br />PAYMEN <br />COMMENTS: <br />FEB 17 2009 <br />SaEMYiRONME HENT <br />HEALTH DF -F fA <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: „A / i <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P/ E: 23001 <br />Fee Amount: S' ` <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />