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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> ERR�EQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> , La• <br /> FACILITY NAME , <br /> SITE ADDRESS �s sf-, T <br /> acreet Number Direction Street Name Cf Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street� <br /> Number �L +r '` Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 12 v� I L2 -7 12— <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 <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 /> OUNTY Ordinance Codes,Standards, M�ATTnE and FEDERAL laws. <br /> frW Lt(m, ->,' V- �n I <br /> APPLICANT'S SIGNATURE: b 'I DATE: '� 'I-71,17 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 t0 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: C0 X) L- L-7--*-'n0DECEIVED <br /> COMMENTS: <br /> MAR 17 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: D L-L V IC—L 14A' EMPLOYEE#: (,D3 2,-J DATE: 3 t-Z 1,01 <br /> ASSIGNED TO: n-t>ENE EMPLOYEE#: r L+2_0 DATE: -3 t7 4 <br /> Date Service Completed (if already completed): SERVICE CODE:/ / P/E: �3 <br /> Fee Amount: ! S' Amount Paid ([) ,5—. CTID Payment Date `-7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />