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SAN JOAOIJIN COUNTY ENVIRONMENTAL HEP-TH DEPARTMENT <br /> SERVICE REQUES" <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME � /� <br /> D !bla atm/ f'f oA- <br /> SITEADDREESS <br /> 7?-'.3 Street Number Direction Key/`-f, ti L�/Sheet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number street Name <br /> CITY STATE ZIP. •; ' <br /> t• <br /> PHONE#1 exc APN# LAND USE APPLICATION# <br /> PHONE#2T• BOS DISTRICT LOCATIQN CODE <br /> ( ) Z II <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME / PHONE# E'tT• <br /> HOMEOrMUMDRES4J ;A`# 33// 6J <br /> .22 <br /> CITY /. / STATE ZIP OF <br /> BILLING ACKNO EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same <br /> acknowledge that all site and/or project specific ENvtRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project O: <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 JOAQun <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Z-, DATE: L� µ 60K12 <br /> PROPERTY/BUSINESS OwNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BmLrNGPARTy p}aofofauthorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at du <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmen <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 tome army representative. '?O01-19.0,q Gu.EC*-- <br /> TYPE OF SERVICE REQUESTED: v4 B cjf'/Ts>, 1O;2.0 NT <br /> COMMENTS: REC0\J <br /> SUN 2 5 2010 <br /> SAN J�SONMENT ENT <br /> HEEALTH DEPJ�� <br /> ACCEPTED BY: EMPLOYEE#: l(��i�J DATE: <br /> ASSIGNED TO: EMPLOYEE#: (•J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: B <br /> Fee Amount: Oft ;W cf Amount Paid �� 3U � Payment Date � gs -Z) <br /> Payment Type ✓ Invoice# Check# 573 Received By: <br /> EHD 4U-02-025 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />