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SAN JOAQUIN L;OUNTY ENVIRONMENTAL HEALTH DENARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 60,A ra'.4 �I 1 Sg oD -7 q 0& <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> MIT r tction LAn*t O Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) C— <br /> eetNumber \./ f—ntr Name <br /> CITY STAT VA <br /> zip <br /> PHONE#1 ENT. APN# LAND USE AP PLICATION# <br /> Flo ' 25 �qNo1a <br /> Ii E#2 EXT. BOS DISTRICT LOCATION CODE <br /> Gv ,C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Vv <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P NE ' I n "7 xT <br /> HOMEO IL ADD S FAX# ✓� !/� <br /> t ) <br /> CITU STATE ZIP i <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, STA E and FEDERAL la <br /> APPLICANT'S SIGNATURE: U 4 Jia 2 DATE: <br /> PROPERTY I BUSINESS OWNER❑ RATOR/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, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: a-h eZ:h0l� <br /> COMMENTS: eAYMENT <br /> C'ihor;ige� o a n RECEIVED <br /> APR 19 2010 <br /> SAN JOACIUIN COUNTY. <br /> ACCEPTED BY: EMPLOYEE#: flarcNVIIi <br /> rn v D T <br /> ASSIGNED TO: �--( EMPLOYEE#: DATE: _//.1- /� <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: <br /> Fee Amount: Amount Paid S2 �D Payment Date <br /> Payment Type V Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />