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SAN JOAQUIiPCOUNTY ENVIRONMENTAL HEALTHIPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />Nt-J bF1 l,L_ <br />HOME Or MAILING ADDRESS j t r �} V1.5 1� <br />/� <br />`C) �jSTATE <br />A 000 ccA to <br />S .-7 2' --?-1 <br />OWNER / OPERA T R <br />CHECK if BILLING ADDRESS <br />FACILITY NAME)� <br />ACCEPTED BY: ©L_,L V C— ( a��A <br />q <br />SITE ADDRESS jJ <br />S <br />I <br />ASSIGNED TO:�- <br />t� � ] <br />EMPLOYEE #: C,-7 3 <br />DATE: Z D <br />9 5-33 <br />Street Number <br />Direction <br />P/ <br />; 4407 <br />Street Name <br />unt Paid <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1 i 45 <br />► t , G.Lf p�-(� (�k�w,� <br />Street Number <br />Received By: [yrs— <br />Street Name <br />CITY �-T (J��y�1i `c- ofv 1 <br />I <br />ST� <br />ZIP n, <br />` <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 1 <br />2-01 -0GO a--oZ <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION DE <br />CONTRACTOR It SERVICE REQUESTOR <br />REQUESTOR T <br />9' �. �/� � �� ern 1 1 <br />��-A <br />I�I L" L�-� <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />t STl?TK t <br />P' <br />--'7 EXT. <br />HOME Or MAILING ADDRESS j t r �} V1.5 1� <br />/� <br />`C) �jSTATE <br />(10) <br />3 n -/ b 8 <br />1 <br />CITY /'4 <br />Zip �l-7 �6; <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 />COUNTY Ordinance Codes, Standards, STATE DERAL laws. a^% <br />APPLICANT'S SIGNATURE: v l,/") DATE: 5`22 i O 9 <br />PROPERTY / BUSINESS OWNER ElOPERATOR/ MANAGER OTHER AUTHORIZED �./ l"' LAGENT ❑ A-M?ic� <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 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: S t iJ S t T� �1'U�F <br />S (�- v<J f�'CQ AJ !%-0,Lr /U�}, - <br />COMMENTS; <br />LA, p,LV-- ,,0L-Ay�) t� �, ,>�� <br />RECEIVED <br />MAY 2 2 2009 <br />0 9 — (/ Ct 8 - D 2-, <br />lcu O$ - 0.3 ? 5-AJSAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />�tJ C E l6 HEALTH DEPAR EN <br />ACCEPTED BY: ©L_,L V C— ( a��A <br />EMPLOYEE #: /^ - <br />10 <br />DATE: <br />ASSIGNED TO:�- <br />EMPLOYEE #: C,-7 3 <br />DATE: Z D <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 3 D L) <br />P/ <br />; 4407 <br />Fee Amount: / <br />unt Paid <br />Payment Date 2 0� <br />Payment Type <br />Invoice # <br />Check # 2 2 3 <br />Received By: [yrs— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />