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SAN JOAQUIi`S`.i7NTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID ti,)T SERVICE REQUEST# <br /> OWNER0,PERATOR �t J <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> M11 GGA, <br /> SITE ADDRESS \' (2-d C� •, G /`'^ '�,/ <br /> Street Number Direction M Street Name — Cit 1 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �A�� S <br /> CHECK If BILLING ADDRESS <br /> BUSINE NAME I , \ PHONE# EXT. <br /> vor MAILING ADDRESS-` FAx <br /> A \ s <br /> CITY SJ ATE IP <br /> G L.� <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 F <br /> activity will be billed to me or my business as identified on this fon post-it®Fax Note 7671 Date pages►d Z. <br /> I also certify that I have prepared this application and that the work T' Fro �G�l <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. Co./ � Co. <br /> APPLICANT'S SIGNATURE: Phone# 15- -1-15 4)0 Phone# <br /> Fax# 7Fax# <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 4 <br /> If APPLICANT is not the BILLING PARTY,proof of autl <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. A , <br /> TYPE OF SERVICE REQUESTED: ME110 <br /> COMMENTS: DEC <br /> S'4Cr 3 2009 <br /> N NV/Rp U/N COU <br /> �C7�-I OEp���NT y <br /> ACCEPTED BY: L�` J EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: �M �`�\'l _ EMPLOYEE#: 39 DATE: el _ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: r b0 C' Amount Paid ' x+17 Payment Date <br /> Payment Type Invoice# Check# Cj 2-0 LJ Received By: L45 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />