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NMENTAL <br />SAN JOAQUIN COUNTYSERVICE REQUEST HEALTH DEPARTMENT <br />`•' FACILITY ID # SERVICE REQUEST # <br />Type of Business or Property ,,o <br />Z S2 op &0;355 <br />`A&w <br />rl., K CHECK If BILLING❑ <br />OWNER I <br />FACILITY NAME <br />SITE ADDRESS !� tNDirectnHOME Ot MAILING ADDRerent from Site Address) serest Number <br />CITY <br />Exr. APN#0�2^ ��O��i <br />PHONE#1 <br />( ) <br />Ext. <br />PHONE#2 <br />CONTRACTOR / SERVICE <br />REQUESTOR <br />BUSINESS <br />HOME Or MAILING ADDRESS <br />T jam , <br />Ips lid° <br />Street Name <br />STATE ZIP <br />LAND USE APPLICATION # <br />LOCATION CODE <br />BOS DISTRICT <br />Z <br />�UESTOR <br />CHECK <br />if BILLING <br />Exr. <br />PHONE# <br />l <br />STATE /A ZIP <br />G C- -;;— {- -,:A- <br />CITY ✓ � V <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent pr <br />Or <br />same, <br />acknowledge that all site and/or project specific ENV IAONMENTALHEALTI-I DEPARTMENT hourly charges associated with this p <br />activity will be billed to me or my business as identified on this form <br />d will be done in accordance with all SAN JOAQUIN <br />I also certify that I have prepared this application and that the work to be performe <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />�/ <br />APPLICANT'S SIGNATURE: DATE*. <br />L'I <br />PROPERTY/BUSINESS OWNER ❑ PERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ Tide <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 />A _ IEC <br />TYPE OF SERVICE REQUESTED: Foal L <br />COMMENTS: <br />ACCEPTED BY: O u v F— <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: Z3 ®, Amount Paid <br />Payment Type I I Invoice # <br />ODEL C^ -^d <br />PAYMENT <br />RECEIVED <br />JUN 2 9 2010 <br />EMPLOYEE M <br />EMPLOYEE #: <br />SERVICECODE: -5'22-- <br />Payment <br />22— <br />Payment Date <br />Check # III lk <br />eo24 f o <br />DATE: (5> L2 m <br />P / E: 2 !_n .T <br />EHD 48-02-025 SR FORM <br />REVISED 11/17/2003 <br />