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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Df P'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sohW con6lC16 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILnY NAME P—eaw kI I, <br /> SITE ADDRESS 3 Do F •� <br /> Street Number Dlreetlan Street Name ✓GIl" " ' 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 /> PHONE#2 EXT. BOB DISTRICT LOCATON CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �f „GG�..q,l lofT <br /> I /.1 �QI/JrTL CHECK if BILLING ADDRESS <br /> BUSINESS NAME ���'MMMMAAAA V` C PHONE# ExT. <br /> v- 513 _ Z <br /> HOME or MAILING ADDRESS O r FAX# <br /> CITY `^1 STATE C ed j- ZIP 41-415-is <br /> 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 1 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: �'1(�( e.l� by (o—!Or 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTITORIZEDAGENT❑ _ ' <br /> ff.4PPLICANT is not the BILLING PARTY proof of authorization to sign is required Title ' <br /> 17: <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 assessaient , <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tirrue it is <br /> provided to me or my representative. — .. _ <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> OCT 11 2010 - <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: LDrxw✓.A e 5 GD EMPLOYEE#: 0'(07 DATE: 10—I I _ <br /> "O <br /> ASSIGNED TO: �-a 4--\ I <br /> EMPLOYEE#: (-242) DATE: 10— 11 <br /> Date Service Completed (If already completed): SERVICE CODE ,S Z>b I PIE: 9(0.12- <br /> Fee Amount: 'al-` Amount Paid Payment Date 1. p �1, 00 <br /> Payment Type L j Invoice# Check# g Recei ed B <br /> EHD 48-02-025 \ SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />