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SAN JOAqwOUNTY ENVIRONMENTAL HEALEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6-1-as Si A-i c a eel 3'7 S -7 <br /> OWNER/OPERATOR 1- <br /> �V`l--C1 DC` —J roa�C� CHECK IfBILUNGADDRESS <br /> ❑ <br /> FACILITY(NAME �v <br /> S h-e LA <br /> SITE ADDRESS -7 S <br /> Street Number Street Namel C eY0 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number W l tree aTm�e T�t�_ <br /> CITY -5b`A STATE C4 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ]� <br /> c3(d) '3((o `f - 4)2-t�—t 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE' <br /> ( ) 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR qx±y <br /> 0\�tQ CHECK If BILLING ADDRESS <br /> BUSINESS NAME W PH�OpE��# EXT• <br /> Seu uLt'e ste.LI�s �V-C-. Q-Q -(n4 3 IF <br /> HOME or MAILING ADDRESS FAX# <br /> i'�b Auk— (40 -:4) - (Q 6'4 <br /> CITY Sa-Li,- dd)—S-� STATE CA ZIP q T1(- <br /> ;I-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,Standards,STATE and FEDERAL laws. `_ / <br /> APPLICANT'S SIGNATURE: JAI�"- h • DATE: /o`P ( 4/0100n <br /> �1 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CcC4L�-Q/- <br /> IfAPPLICANT 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: �j( �� ,Q('f(,� <br /> COMMENTS: T lJ '&C - 6r U-e�`&AR Url5ttLt UK d&V IrFf+rlWY .(E <br /> V .:� s�) 1 0 2009 <br /> 3'Jl� d Z40--ONNIENT HEALTH <br /> 5AN JOAavIN gout l�itu"i�1�SERVICES <br /> ENVIRONM�TMENT <br /> ACCEPTED BY: EMPLOYE#: DATE:! 3 r <br /> ASSIGNED TO: �� EMPLOYEE#: Z. DATE: t G <br /> Date Service Completed (if alr dy completed): SERVICE CODE: rq PIE: <br /> Fee Amount: 3 /�� Amount Paid 3 5 _ Payment Date p <br /> Payment Type Invoice# Check# b,r1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />